gender reassignment surgery breast removal

• skip to Cookie Notice
• skip to Main Navigation
• skip to Main Content
• skip to Footer
• Find a Doctor
• Find a Location
• Appointments & Referrals
• Patient Gateway
• Español
• Leadership Team
• Quality & Safety
• Equity & Inclusion
• Community Health
• Education & Training
• Centers & Departments
• Browse Treatments
• Browse Conditions A-Z
• View All Centers & Departments
• Clinical Trials
• Cancer Clinical Trials
• Cancer Center
• Digestive Healthcare Center
• Heart Center
• Mass General for Children
• Neuroscience
• Orthopaedic Surgery
• Information for Visitors
• Maps & Directions
• Parking & Shuttles
• Services & Amenities
• Accessibility
• Visiting Boston
• International Patients
• Medical Records
• Billing, Insurance & Financial Assistance
• Privacy & Security
• Patient Experience
• Explore Our Laboratories
• Industry Collaborations
• Research & Innovation News
• About the Research Institute
• Innovation Programs
• Education & Community Outreach
• Support Our Research
• Find a Researcher
• News & Events
• Ways to Give
• Patient Rights & Advocacy
• Website Terms of Use
• Apollo (Intranet)

Plastic & Reconstructive Surgery

• Like us on Facebook
• Follow us on Twitter
• See us on LinkedIn
• Print this page

Transgender Surgical Program

• 617-726-3525

Contact Information

Phone: 617-726-3525 Fax: 617-724-7126

Email: [email protected]

Explore This Treatment

About gender-affirming surgery at mass general.

Specialists in the  Transgender Health Program  and Transgender Surgical Program at Massachusetts General Hospital are dedicated to ensuring a welcoming and affirming environment for all patients. We offer patients a wide spectrum of gender-affirming services to support them throughout their entire care journey, including comprehensive primary care, surgical treatment, hormone management, case management and behavioral health support.

The Transgender Surgical Program is a collaboration with specialists from the Mass General  Division of Plastic and Reconstructive Surgery , the  Department of Urology  and the  Department of Obstetrics and Gynecology . Our multidisciplinary surgical team works closely with providers from the Transgender Health Program and every patient to develop a safe and all-inclusive surgical plan that aligns with the patient’s personal goals.

Gender-Affirming Surgical Procedures

Our expert team performs a variety of highly specialized gender-affirming surgical procedures tailored to meet the needs of transgender and gender-nonconforming patients.

• Vaginoplasty , sometimes referred to as bottom surgery, is a surgery that is used to create a vulva, labia, and vaginal canal
• Orchiectomy , also known as testicle removal surgery and/or bottom surgery, is a procedure in which the testicles are surgically removed
• Hysterectomy and/or oophorectomy is a surgery that involves the removal of the uterus and, in some case, the ovaries
• Phalloplasty , sometimes referred to as bottom surgery, is surgery to create a penis. It can include a variety of different procedures, depending on individual goals
• Mastectomy , sometimes referred to as top surgery, is a surgery to remove breast tissue from the chest
• Breast augmentation is surgery that uses implants made of silicone or saline to enhance the size of a person’s natural breasts
• Facial feminization or masculinization is surgery to alter facial features—the chin, nose, cheeks, forehead, etc.—to create a more feminine or masculine facial structure
• Voice feminization surgery is a procedure that alters the pitch and quality of an individual's voice to align it with a more feminine sound though surgery that involves lengthening the vocal cords or adjusting the tension of the vocal cords. Before undergoing surgical intervention, patients will work with a speech therapist specializing in voice feminization
• Voice masculinization surgery is a procedure that alters the pitch and quality of an individual's voice to align it with a more masculine sound though surgery to decrease the tension of the vocal cords. In addition to surgery, some individuals may benefit from speech therapy to further refine their vocal skills and communication. This procedure is not common, as only 75% of people can masculinize their voice with hormone therapy

Frequently Asked Questions About Gender-Affirming Surgery

For genital or “bottom” surgery, the first step is to schedule an initial visit with the Transgender Health Program. To schedule this appointment, call 617-726-3525 or email us . For breast or “top” surgery, you are not required to schedule an intake visit with the Transgender Health Program, unless you need a referral for support services. Instead, please contact the Transgender Surgery Program team at 617-726-3525 to learn how to proceed with a surgical consult. Providers should fax referrals to 617-724-7126.

Following confirmation from the Transgender Health Program that you are ready to move forward with bottom surgery, the Transgender Surgery Program team will contact you to set up a surgical consult.

Fertility preservation offers the opportunity to freeze eggs or sperm to be used for building a family in the future. This can be done prior to initiation of gender affirming hormone therapy or surgery. For some, it can also be used after hormonal therapy has already been started. Resources and care are also available for coordinating use of eggs or sperm from another person (donor) or for another individual to carry a pregnancy (gestational carrier).

Patients who desire fertility preservation or family building through Mass General must:

• Complete a consultation with the Mass General Fertility Center
• Be of reproductive age (requirements vary by family building plan)
• Follow center-specific guidance and protocols for selected treatment

During your surgical consultation, your physician will ask you about your fertility preservation goals and will assist you with setting up a consultation with a fertility specialist. We are committed to supporting you and guiding you through this process.

Required documents prior to gender-affirming surgery vary depending on the type of procedure. Our surgical program coordinator will assist you with questions and provide you with more information during your surgical consult.

Once we’ve scheduled a date for your surgery, we will submit a prior authorization for surgery to your insurance company for approval. Some out-of-network insurances may require you to obtain prior authorization for surgical consultations. Please reach out to your insurance company to determine what is required. Our dedicated surgical coordinator is happy to assist you with this process.

There are medical rates at many of the surrounding local hospitals. Depending on the procedure, you may need to remain local for a few weeks. If you are interested in medical rates, our dedicated surgical coordinator will be happy to provide you with more information.

Patient Stories

Patients who underwent gender-affirming surgery at Mass General share their experiences.

Finally, Herself: Elise’s Journey to Gender-Affirming Surgery

When Elise first heard of gender-affirming surgery, it seemed next to impossible in her situation. After a few years filled with research and conversations about her gender identity, what seemed impossible became achievable. She sought care with the Mass General Transgender Health Program team.

Tanner Chose Mass General for Gender-Affirming Care

"I wouldn’t have been able to do it if I didn’t have my team by my side every step of the way. I went from worrying, to feeling grateful," Tanner Bonanza, gender-affirming surgical patient.

Meet Our Team

The Mass General Transgender Surgical Program and the Transgender Health Program form a multidisciplinary and collaborative team of providers and staff who work together to provide gender-affirming care for all patients.

Jay Austen, MD

• Chief, Plastic and Reconstructive Surgery
• Chief, Division of Burn Surgery
• Interim Chief of the Department of Oral & Maxillofacial Surgery

Branko Bojovic, MD

• Plastic and Reconstructive Surgery
• Department of Surgery

Katherine Carruthers, MD, MS

• Attending Surgeon, Massachusetts General Hospital

Beth Drzewiecki, MD

• Pediatric Urology, MassGeneral Hospital for Children

Rich Ehrlichman, MD

• Assistant Professor of Surgery, Harvard Medical School
• Assistant Surgeon, Massachusetts General Hospital

Ariel Frey-Vogel, MD, MAT

• Primary Care
• Department of Medicine
• Department of Pediatrics

Youngwu Kim, MD

• Urogynecologist
• Urogynecology and Reconstructive Pelvic Surgeon

Jenny Siegel, MD

Eleanor Tomczyk, MD

Milena Weinstein, MD

• Chief of Urogynecology and Reconstructive Pelvic Surgery (URPS)
• Co-chair, Center for Pelvic Floor Disorders
• Director of Research, Urogynecology and Reconstructive Pelvic Surgery Fellowship

Jonathan Winograd, MD

• Associate Visiting Surgeon, Massachusetts General Hospital
• Associate Professor, Harvard Medical School

Telehealth at Mass General

Virtual visits allow you to conveniently meet with your provider from home—either online (over your computer or device) or by phone.

A Top Hospital in America

Mass General is recognized as a top hospital on the U.S. News Best Hospitals Honor Roll for 2024-2025.

If you would like to request an appointment with or refer a patient to the Division of Plastic and Reconstructive Surgery, please use the following contact information.

Transgender Mastectomy (Top Surgery)

What Do our Patients Say ?

Dr.transman, let’s start your  journey from here.

Our experience, our technologically-advanced facilities and our compassionate staff are the best in the business for transgender confirmation procedures, holistic therapy and the overall patient experience.

Gender-Affirming Surgery (Top Surgery)

Gender-affirming surgery is a collection of surgical procedures for adults ages 18 and older diagnosed with gender dysphoria. The operations are often referred to as “top surgery" and "bottom surgery.” Duke Health offers several top surgery options to transgender, gender-diverse, nonbinary, and gender-nonconforming adults who want their appearance to align with their internal identity. If, after a consultation with our doctors, you decide to pursue top surgery, we work toward a positive outcome that improves your physical, emotional, and psychological well-being.

What You Should Know About Gender-Affirming Surgery

Choosing to pursue gender-affirming surgery is an individual, personal decision. You’ll want to consider how it will change your quality of life and how it will help you achieve your goals.

Gender Dysphoria One important step is understanding how much you are affected by gender dysphoria, a diagnosis that the American Psychiatric Association defines as a conflict between your physical or assigned gender and the gender with which you identify. 

Candidates for Top Surgery To be a candidate for top surgery, you must:

• Be 18 or older
• Be in good health without illness or a condition that can increase your risk of surgical complications
• Have a BMI under 35
• Provide a clearance letter from your mental health or primary care provider stating you have gender dysphoria and you have been living in your assigned gender for at least 12 months

Top Surgery Costs Some private insurance plans will cover transgender surgery when it is used to address a diagnosis of gender dysphoria. Check with your insurance plan to determine your coverage.

Understanding Which Top Surgery Is Right for You There are several approaches to transgender surgery. We will review these with you during your initial consultation and make a recommendation based on your physical exam and medical history.

You May Have Scars Your surgeon will use the natural contours of your breasts to minimize scarring as much as possible. In some cases, depending on your breast size and weight, a small bunching of tissue may result in scars known as “dog ears” following mastectomy. These can be corrected later with revision surgery.

Understand the Risks Top surgery carries the same risks as other standard surgeries. These include the risk of bleeding and infection and risks associated with general anesthesia. Your doctor will discuss these risks with you if surgery is recommended.

Initial Consultation and Tests

Consultation and Exam Your first step will be an in-person consultation. Our providers spend time meeting with you, evaluating your anatomy, answering your questions, and determining if this surgery will help you achieve your goals.

Your surgeon will review your family history, general health status, lifestyle habits such as smoking, previous operations, any medications you may be taking, and conditions that can put you at risk for surgery.

Measurements, Photographs, Tests Your breasts will be measured and assessed for size and shape, and photographs may be taken for your medical record. Before treatment is recommended, you will also undergo one or more of the following tests.

• Blood tests may be necessary to evaluate your hormone levels. Pre-surgical testing also requires several blood tests to assess your liver and kidney function and to determine if you have a previously undetected infection, blood disorder, or anemia.
• A mammogram may be performed to look for any underlying breast abnormalities. Additional imaging, including ultrasound and MRI, may also be requested.

Recommending Treatment Based on these findings, your surgeon will recommend an approach to surgery. She will discuss the expected outcome, potential risks and complications, and your post-operation recovery. Alternatively, your surgeon may recommend that you lose weight, quit smoking, or discontinue medication before surgery to ensure you experience the best possible outcome.

If You Take Hormone Therapy Some gender-affirming hormone therapy , such as testosterone, can be continued if you pursue transgender surgery. Others, such as anti-estrogen therapy, may be stopped. Your surgeon will explain what you need to do to prepare for surgery.

Top Surgeries

Chest reconstruction - mastectomy, breast reduction.

We use different approaches to remove breast tissue and contour breasts to appear more masculine. The right approach depends on your anatomy and the size of your breasts. Techniques for medium to large breasts include nipple-sparing, double incision, buttonhole, and inverted-T incision. Keyhole and peri-areolar techniques may be used for smaller breasts or for those with good skin elasticity. Your surgeon will discuss your options with you after your physical exam and consultation.

Breast Augmentation

There are also many different approaches to breast augmentation, including the use of implants and fat grafting. We can also combine breast augmentation with body contouring, liposuction, and neurotoxin injections such as Botox injections and dermal fillers.

The Procedure Length

On average, top surgery takes about two to three hours and is performed under general anesthesia in an outpatient ambulatory surgery center. In some case, an overnight stay may be required. Sometimes a second procedure is needed to further tighten skin and achieve optimal cosmetic results.

Your chest will be wrapped in bandages, and a compression chest vest or surgical bra will be worn after the procedure. Drains will be required after mastectomy but not after breast augmentation. Initial recovery takes about one week. It may take three to six months for all swelling to subside and scars to fade.

Duke University Hospital is proud of our team and the exceptional care they provide. They are why we are once again recognized as the best hospital in North Carolina, and nationally ranked in 11 adult and 10 pediatric specialties by U.S. News & World Report for 2024–2025.

Why Choose Duke

You'll Work With a Plastic Surgeon Experienced in Gender Affirmation Surgery Our plastic surgeon has worked with many individuals seeking gender confirmation surgery. She is fellowship trained in body contouring, which means she has completed additional training in procedures that improve the body shape. Our surgeon is also a member of the World Professional Association for Transgender Health (WPATH), a nonprofit organization working to standardize and improve transgender care.

Duke Health Is Committed to the LGBTQ+ Community Duke Health values diversity and has taken many steps to show its commitment to eliminating discrimination, promoting equality, and standing beside our lesbian, gay, bisexual, transgender, and queer (LGBTQ+) community. Duke University Hospital, Duke Regional Hospital, and Duke Raleigh Hospital are recognized as LGBTQ+ Healthcare Equality Leaders by the Human Rights Campaign Foundation for perfect scores across areas of patient-centered care, support services, and inclusive health insurance policies for LGBTQ+ patients.

Related Care

• Gender-Affirming Hormone Therapy

• Patient Care & Health Information
• Tests & Procedures
• Feminizing surgery

Feminizing surgery, also called gender-affirming surgery or gender-confirmation surgery, involves procedures that help better align the body with a person's gender identity. Feminizing surgery includes several options, such as top surgery to increase the size of the breasts. That procedure also is called breast augmentation. Bottom surgery can involve removal of the testicles, or removal of the testicles and penis and the creation of a vagina, labia and clitoris. Facial procedures or body-contouring procedures can be used as well.

Not everybody chooses to have feminizing surgery. These surgeries can be expensive, carry risks and complications, and involve follow-up medical care and procedures. Certain surgeries change fertility and sexual sensations. They also may change how you feel about your body.

Your health care team can talk with you about your options and help you weigh the risks and benefits.

Products & Services

• A Book: Mayo Clinic Family Health Book
• Available Sexual Health Solutions at Mayo Clinic Store
• Newsletter: Mayo Clinic Health Letter — Digital Edition

Why it's done

Many people seek feminizing surgery as a step in the process of treating discomfort or distress because their gender identity differs from their sex assigned at birth. The medical term for this is gender dysphoria.

For some people, having feminizing surgery feels like a natural step. It's important to their sense of self. Others choose not to have surgery. All people relate to their bodies differently and should make individual choices that best suit their needs.

Feminizing surgery may include:

• Removal of the testicles alone. This is called orchiectomy.
• Removal of the penis, called penectomy.
• Removal of the testicles.
• Creation of a vagina, called vaginoplasty.
• Creation of a clitoris, called clitoroplasty.
• Creation of labia, called labioplasty.
• Breast surgery. Surgery to increase breast size is called top surgery or breast augmentation. It can be done through implants, the placement of tissue expanders under breast tissue, or the transplantation of fat from other parts of the body into the breast.
• Plastic surgery on the face. This is called facial feminization surgery. It involves plastic surgery techniques in which the jaw, chin, cheeks, forehead, nose, and areas surrounding the eyes, ears or lips are changed to create a more feminine appearance.
• Tummy tuck, called abdominoplasty.
• Buttock lift, called gluteal augmentation.
• Liposuction, a surgical procedure that uses a suction technique to remove fat from specific areas of the body.
• Voice feminizing therapy and surgery. These are techniques used to raise voice pitch.
• Tracheal shave. This surgery reduces the thyroid cartilage, also called the Adam's apple.
• Scalp hair transplant. This procedure removes hair follicles from the back and side of the head and transplants them to balding areas.
• Hair removal. A laser can be used to remove unwanted hair. Another option is electrolysis, a procedure that involves inserting a tiny needle into each hair follicle. The needle emits a pulse of electric current that damages and eventually destroys the follicle.

Your health care provider might advise against these surgeries if you have:

• Significant medical conditions that haven't been addressed.
• Behavioral health conditions that haven't been addressed.
• Any condition that limits your ability to give your informed consent.

Like any other type of major surgery, many types of feminizing surgery pose a risk of bleeding, infection and a reaction to anesthesia. Other complications might include:

• Delayed wound healing
• Fluid buildup beneath the skin, called seroma
• Bruising, also called hematoma
• Changes in skin sensation such as pain that doesn't go away, tingling, reduced sensation or numbness
• Damaged or dead body tissue — a condition known as tissue necrosis — such as in the vagina or labia
• A blood clot in a deep vein, called deep vein thrombosis, or a blood clot in the lung, called pulmonary embolism
• Development of an irregular connection between two body parts, called a fistula, such as between the bladder or bowel into the vagina
• Urinary problems, such as incontinence
• Pelvic floor problems
• Permanent scarring
• Loss of sexual pleasure or function
• Worsening of a behavioral health problem

Certain types of feminizing surgery may limit or end fertility. If you want to have biological children and you're having surgery that involves your reproductive organs, talk to your health care provider before surgery. You may be able to freeze sperm with a technique called sperm cryopreservation.

How you prepare

Before surgery, you meet with your surgeon. Work with a surgeon who is board certified and experienced in the procedures you want. Your surgeon talks with you about your options and the potential results. The surgeon also may provide information on details such as the type of anesthesia that will be used during surgery and the kind of follow-up care that you may need.

Follow your health care team's directions on preparing for your procedures. This may include guidelines on eating and drinking. You may need to make changes in the medicine you take and stop using nicotine, including vaping, smoking and chewing tobacco.

Because feminizing surgery might cause physical changes that cannot be reversed, you must give informed consent after thoroughly discussing:

• Risks and benefits
• Alternatives to surgery
• Expectations and goals
• Social and legal implications
• Potential complications
• Impact on sexual function and fertility

Evaluation for surgery

Before surgery, a health care provider evaluates your health to address any medical conditions that might prevent you from having surgery or that could affect the procedure. This evaluation may be done by a provider with expertise in transgender medicine. The evaluation might include:

• A review of your personal and family medical history
• A physical exam
• A review of your vaccinations
• Screening tests for some conditions and diseases
• Identification and management, if needed, of tobacco use, drug use, alcohol use disorder, HIV or other sexually transmitted infections
• Discussion about birth control, fertility and sexual function

You also may have a behavioral health evaluation by a health care provider with expertise in transgender health. That evaluation might assess:

• Gender identity
• Gender dysphoria
• Mental health concerns
• Sexual health concerns
• The impact of gender identity at work, at school, at home and in social settings
• The role of social transitioning and hormone therapy before surgery
• Risky behaviors, such as substance use or use of unapproved hormone therapy or supplements
• Support from family, friends and caregivers
• Your goals and expectations of treatment
• Care planning and follow-up after surgery

Other considerations

Health insurance coverage for feminizing surgery varies widely. Before you have surgery, check with your insurance provider to see what will be covered.

Before surgery, you might consider talking to others who have had feminizing surgery. If you don't know someone, ask your health care provider about support groups in your area or online resources you can trust. People who have gone through the process may be able to help you set your expectations and offer a point of comparison for your own goals of the surgery.

What you can expect

Facial feminization surgery.

Facial feminization surgery may involve a range of procedures to change facial features, including:

• Moving the hairline to create a smaller forehead
• Enlarging the lips and cheekbones with implants
• Reshaping the jaw and chin
• Undergoing skin-tightening surgery after bone reduction

These surgeries are typically done on an outpatient basis, requiring no hospital stay. Recovery time for most of them is several weeks. Recovering from jaw procedures takes longer.

Tracheal shave

A tracheal shave minimizes the thyroid cartilage, also called the Adam's apple. During this procedure, a small cut is made under the chin, in the shadow of the neck or in a skin fold to conceal the scar. The surgeon then reduces and reshapes the cartilage. This is typically an outpatient procedure, requiring no hospital stay.

Top surgery

• Breast augmentation incisions

As part of top surgery, the surgeon makes cuts around the areola, near the armpit or in the crease under the breast.

• Placement of breast implants or tissue expanders

During top surgery, the surgeon places the implants under the breast tissue. If feminizing hormones haven't made the breasts large enough, an initial surgery might be needed to have devices called tissue expanders placed in front of the chest muscles.

Hormone therapy with estrogen stimulates breast growth, but many people aren't satisfied with that growth alone. Top surgery is a surgical procedure to increase breast size that may involve implants, fat grafting or both.

During this surgery, a surgeon makes cuts around the areola, near the armpit or in the crease under the breast. Next, silicone or saline implants are placed under the breast tissue. Another option is to transplant fat, muscles or tissue from other parts of the body into the breasts.

If feminizing hormones haven't made the breasts large enough for top surgery, an initial surgery may be needed to place devices called tissue expanders in front of the chest muscles. After that surgery, visits to a health care provider are needed every few weeks to have a small amount of saline injected into the tissue expanders. This slowly stretches the chest skin and other tissues to make room for the implants. When the skin has been stretched enough, another surgery is done to remove the expanders and place the implants.

Genital surgery

• Anatomy before and after penile inversion

During penile inversion, the surgeon makes a cut in the area between the rectum and the urethra and prostate. This forms a tunnel that becomes the new vagina. The surgeon lines the inside of the tunnel with skin from the scrotum, the penis or both. If there's not enough penile or scrotal skin, the surgeon might take skin from another area of the body and use it for the new vagina as well.

• Anatomy before and after bowel flap procedure

A bowel flap procedure might be done if there's not enough tissue or skin in the penis or scrotum. The surgeon moves a segment of the colon or small bowel to form a new vagina. That segment is called a bowel flap or conduit. The surgeon reconnects the remaining parts of the colon.

Orchiectomy

Orchiectomy is a surgery to remove the testicles. Because testicles produce sperm and the hormone testosterone, an orchiectomy might eliminate the need to use testosterone blockers. It also may lower the amount of estrogen needed to achieve and maintain the appearance you want.

This type of surgery is typically done on an outpatient basis. A local anesthetic may be used, so only the testicular area is numbed. Or the surgery may be done using general anesthesia. This means you are in a sleep-like state during the procedure.

To remove the testicles, a surgeon makes a cut in the scrotum and removes the testicles through the opening. Orchiectomy is typically done as part of the surgery for vaginoplasty. But some people prefer to have it done alone without other genital surgery.

Vaginoplasty

Vaginoplasty is the surgical creation of a vagina. During vaginoplasty, skin from the shaft of the penis and the scrotum is used to create a vaginal canal. This surgical approach is called penile inversion. In some techniques, the skin also is used to create the labia. That procedure is called labiaplasty. To surgically create a clitoris, the tip of the penis and the nerves that supply it are used. This procedure is called a clitoroplasty. In some cases, skin can be taken from another area of the body or tissue from the colon may be used to create the vagina. This approach is called a bowel flap procedure. During vaginoplasty, the testicles are removed if that has not been done previously.

Some surgeons use a technique that requires laser hair removal in the area of the penis and scrotum to provide hair-free tissue for the procedure. That process can take several months. Other techniques don't require hair removal prior to surgery because the hair follicles are destroyed during the procedure.

After vaginoplasty, a tube called a catheter is placed in the urethra to collect urine for several days. You need to be closely watched for about a week after surgery. Recovery can take up to two months. Your health care provider gives you instructions about when you may begin sexual activity with your new vagina.

After surgery, you're given a set of vaginal dilators of increasing sizes. You insert the dilators in your vagina to maintain, lengthen and stretch it. Follow your health care provider's directions on how often to use the dilators. To keep the vagina open, dilation needs to continue long term.

Because the prostate gland isn't removed during surgery, you need to follow age-appropriate recommendations for prostate cancer screening. Following surgery, it is possible to develop urinary symptoms from enlargement of the prostate.

Dilation after gender-affirming surgery

This material is for your education and information only. This content does not replace medical advice, diagnosis and treatment. If you have questions about a medical condition, always talk with your health care provider.

Narrator: Vaginal dilation is important to your recovery and ongoing care. You have to dilate to maintain the size and shape of your vaginal canal and to keep it open.

Jessi: I think for many trans women, including myself, but especially myself, I looked forward to one day having surgery for a long time. So that meant looking up on the internet what the routines would be, what the surgery entailed. So I knew going into it that dilation was going to be a very big part of my routine post-op, but just going forward, permanently.

Narrator: Vaginal dilation is part of your self-care. You will need to do vaginal dilation for the rest of your life.

Alissa (nurse): If you do not do dilation, your vagina may shrink or close. If that happens, these changes might not be able to be reversed.

Narrator: For the first year after surgery, you will dilate many times a day. After the first year, you may only need to dilate once a week. Most people dilate for the rest of their life.

Jessi: The dilation became easier mostly because I healed the scars, the stitches held up a little bit better, and I knew how to do it better. Each transgender woman's vagina is going to be a little bit different based on anatomy, and I grew to learn mine. I understand, you know, what position I needed to put the dilator in, how much force I needed to use, and once I learned how far I needed to put it in and I didn't force it and I didn't worry so much on oh, did I put it in too far, am I not putting it in far enough, and I have all these worries and then I stress out and then my body tenses up. Once I stopped having those thoughts, I relaxed more and it was a lot easier.

Narrator: You will have dilators of different sizes. Your health care provider will determine which sizes are best for you. Dilation will most likely be painful at first. It's important to dilate even if you have pain.

Alissa (nurse): Learning how to relax the muscles and breathe as you dilate will help. If you wish, you can take the pain medication recommended by your health care team before you dilate.

Narrator: Dilation requires time and privacy. Plan ahead so you have a private area at home or at work. Be sure to have your dilators, a mirror, water-based lubricant and towels available. Wash your hands and the dilators with warm soapy water, rinse well and dry on a clean towel. Use a water-based lubricant to moisten the rounded end of the dilators. Water-based lubricants are available over-the-counter. Do not use oil-based lubricants, such as petroleum jelly or baby oil. These can irritate the vagina. Find a comfortable position in bed or elsewhere. Use pillows to support your back and thighs as you lean back to a 45-degree angle. Start your dilation session with the smallest dilator. Hold a mirror in one hand. Use the other hand to find the opening of your vagina. Separate the skin. Relax through your hips, abdomen and pelvic floor. Take slow, deep breaths. Position the rounded end of the dilator with the lubricant at the opening to your vaginal canal. The rounded end should point toward your back. Insert the dilator. Go slowly and gently. Think of its path as a gentle curving swoop. The dilator doesn't go straight in. It follows the natural curve of the vaginal canal. Keep gentle down and inward pressure on the dilator as you insert it. Stop when the dilator's rounded end reaches the end of your vaginal canal. The dilators have dots or markers that measure depth. Hold the dilator in place in your vaginal canal. Use gentle but constant inward pressure for the correct amount of time at the right depth for you. If you're feeling pain, breathe and relax the muscles. When time is up, slowly remove the dilator, then repeat with the other dilators you need to use. Wash the dilators and your hands. If you have increased discharge following dilation, you may want to wear a pad to protect your clothing.

Jessi: I mean, it's such a strange, unfamiliar feeling to dilate and to have a dilator, you know to insert a dilator into your own vagina. Because it's not a pleasurable experience, and it's quite painful at first when you start to dilate. It feels much like a foreign body entering and it doesn't feel familiar and your body kind of wants to get it out of there. It's really tough at the beginning, but if you can get through the first month, couple months, it's going to be a lot easier and it's not going to be so much of an emotional and uncomfortable experience.

Narrator: You need to stay on schedule even when traveling. Bring your dilators with you. If your schedule at work creates challenges, ask your health care team if some of your dilation sessions can be done overnight.

Alissa (nurse): You can't skip days now and do more dilation later. You must do dilation on schedule to keep vaginal depth and width. It is important to dilate even if you have pain. Dilation should cause less pain over time.

Jessi: I hear that from a lot of other women that it's an overwhelming experience. There's lots of emotions that are coming through all at once. But at the end of the day for me, it was a very happy experience. I was glad to have the opportunity because that meant that while I have a vagina now, at the end of the day I had a vagina. Yes, it hurts, and it's not pleasant to dilate, but I have the vagina and it's worth it. It's a long process and it's not going to be easy. But you can do it.

Narrator: If you feel dilation may not be working or you have any questions about dilation, please talk with a member of your health care team.

Research has found that gender-affirming surgery can have a positive impact on well-being and sexual function. It's important to follow your health care provider's advice for long-term care and follow-up after surgery. Continued care after surgery is associated with good outcomes for long-term health.

Before you have surgery, talk to members of your health care team about what to expect after surgery and the ongoing care you may need.

Clinical trials

Explore Mayo Clinic studies of tests and procedures to help prevent, detect, treat or manage conditions.

Feminizing surgery care at Mayo Clinic

• Tangpricha V, et al. Transgender women: Evaluation and management. https://www.uptodate.com/ contents/search. Accessed Aug. 16, 2022.
• Erickson-Schroth L, ed. Surgical transition. In: Trans Bodies, Trans Selves: A Resource by and for Transgender Communities. 2nd ed. Kindle edition. Oxford University Press; 2022. Accessed Aug. 17, 2022.
• Coleman E, et al. Standards of care for the health of transgender and gender diverse people, version 8. International Journal of Transgender Health. 2022; doi:10.1080/26895269.2022.2100644.
• AskMayoExpert. Gender-affirming procedures (adult). Mayo Clinic; 2022.
• Nahabedian, M. Implant-based breast reconstruction and augmentation. https://www.uptodate.com/contents/search. Accessed Aug. 17, 2022.
• Erickson-Schroth L, ed. Medical transition. In: Trans Bodies, Trans Selves: A Resource by and for Transgender Communities. 2nd ed. Kindle edition. Oxford University Press; 2022. Accessed Aug. 17, 2022.
• Ferrando C, et al. Gender-affirming surgery: Male to female. https://www.uptodate.com/contents/search. Accessed Aug. 17, 2022.
• Doctors & Departments
• Care at Mayo Clinic

Mayo Clinic does not endorse companies or products. Advertising revenue supports our not-for-profit mission.

• Opportunities

Mayo Clinic Press

Check out these best-sellers and special offers on books and newsletters from Mayo Clinic Press .

• Mayo Clinic on Incontinence - Mayo Clinic Press Mayo Clinic on Incontinence
• The Essential Diabetes Book - Mayo Clinic Press The Essential Diabetes Book
• Mayo Clinic on Hearing and Balance - Mayo Clinic Press Mayo Clinic on Hearing and Balance
• FREE Mayo Clinic Diet Assessment - Mayo Clinic Press FREE Mayo Clinic Diet Assessment
• Mayo Clinic Health Letter - FREE book - Mayo Clinic Press Mayo Clinic Health Letter - FREE book

5X Challenge

Thanks to generous benefactors, your gift today can have 5X the impact to advance AI innovation at Mayo Clinic.

• Election 2024
• Entertainment
• Newsletters
• Photography
• AP Buyline Personal Finance
• AP Buyline Shopping
• Press Releases
• Israel-Hamas War
• Russia-Ukraine War
• Global elections
• Asia Pacific
• Latin America
• Middle East
• Election results
• Google trends
• AP & Elections
• U.S. Open Tennis
• Paralympic Games
• College football
• Auto Racing
• Movie reviews
• Book reviews
• Financial Markets
• Business Highlights
• Financial wellness
• Artificial Intelligence
• Social Media

Trans kids’ treatment can start younger, new guidelines say

This photo provided by Laura Short shows Eli Bundy on April 15, 2022 at Deception Pass in Washington. In South Carolina, where a proposed law would ban transgender treatments for kids under age 18, Eli Bundy hopes to get breast removal surgery next year before college. Bundy, 18, who identifies as nonbinary, supports updated guidance from an international transgender health group that recommends lower ages for some treatments. (Laura Short via AP)

FILE - Dr. David Klein, right, an Air Force Major and chief of adolescent medicine at Fort Belvoir Community Hospital, listens as Amanda Brewer, left, speaks with her daughter, Jenn Brewer, 13, as the teenager has blood drawn during a monthly appointment for monitoring her treatment at the hospital in Fort Belvoir, Va., on Sept. 7, 2016. Brewer is transitioning from male to female. (AP Photo/Jacquelyn Martin, File)

• Copy Link copied

A leading transgender health association has lowered its recommended minimum age for starting gender transition treatment, including sex hormones and surgeries.

The World Professional Association for Transgender Health said hormones could be started at age 14, two years earlier than the group’s previous advice, and some surgeries done at age 15 or 17, a year or so earlier than previous guidance. The group acknowledged potential risks but said it is unethical and harmful to withhold early treatment.

The association provided The Associated Press with an advance copy of its update ahead of publication in a medical journal, expected later this year. The international group promotes evidence-based standards of care and includes more than 3,000 doctors, social scientists and others involved in transgender health issues.

The update is based on expert opinion and a review of scientific evidence on the benefits and harms of transgender medical treatment in teens whose gender identity doesn’t match the sex they were assigned at birth, the group said. Such evidence is limited but has grown in the last decade, the group said, with studies suggesting the treatments can improve psychological well-being and reduce suicidal behavior.

Starting treatment earlier allows transgender teens to experience physical puberty changes around the same time as other teens, said Dr. Eli Coleman, chair of the group’s standards of care and director of the University of Minnesota Medical School’s human sexuality program.

But he stressed that age is just one factor to be weighed. Emotional maturity, parents’ consent, longstanding gender discomfort and a careful psychological evaluation are among the others.

“Certainly there are adolescents that do not have the emotional or cognitive maturity to make an informed decision,” he said. “That is why we recommend a careful multidisciplinary assessment.”

The updated guidelines include recommendations for treatment in adults, but the teen guidance is bound to get more attention. It comes amid a surge in kids referred to clinics offering transgender medical treatment , along with new efforts to prevent or restrict the treatment.

Many experts say more kids are seeking such treatment because gender-questioning children are more aware of their medical options and facing less stigma.

Critics, including some from within the transgender treatment community, say some clinics are too quick to offer irreversible treatment to kids who would otherwise outgrow their gender-questioning.

Psychologist Erica Anderson resigned her post as a board member of the World Professional Association for Transgender Health last year after voicing concerns about “sloppy” treatment given to kids without adequate counseling.

She is still a group member and supports the updated guidelines, which emphasize comprehensive assessments before treatment. But she says dozens of families have told her that doesn’t always happen.

“They tell me horror stories. They tell me, ‘Our child had 20 minutes with the doctor’” before being offered hormones, she said. “The parents leave with their hair on fire.’’

Estimates on the number of transgender youth and adults worldwide vary, partly because of different definitions. The association’s new guidelines say data from mostly Western countries suggest a range of between a fraction of a percent in adults to up to 8% in kids.

Anderson said she’s heard recent estimates suggesting the rate in kids is as high as 1 in 5 — which she strongly disputes. That number likely reflects gender-questioning kids who aren’t good candidates for lifelong medical treatment or permanent physical changes, she said.

Still, Anderson said she condemns politicians who want to punish parents for allowing their kids to receive transgender treatment and those who say treatment should be banned for those under age 18.

“That’s just absolutely cruel,’’ she said.

Dr. Marci Bowers, the transgender health group’s president-elect, also has raised concerns about hasty treatment, but she acknowledged the frustration of people who have been “forced to jump through arbitrary hoops and barriers to treatment by gatekeepers ... and subjected to scrutiny that is not applied to another medical diagnosis.’’

Gabe Poulos, 22, had breast removal surgery at age 16 and has been on sex hormones for seven years. The Asheville, North Carolina, resident struggled miserably with gender discomfort before his treatment.

Poulos said he’s glad he was able to get treatment at a young age.

“Transitioning under the roof with your parents so they can go through it with you, that’s really beneficial,’’ he said. “I’m so much happier now.’’

In South Carolina, where a proposed law would ban transgender treatments for kids under age 18, Eli Bundy has been waiting to get breast removal surgery since age 15. Now 18, Bundy just graduated from high school and is planning to have surgery before college.

Bundy, who identifies as nonbinary, supports easing limits on transgender medical care for kids.

“Those decisions are best made by patients and patient families and medical professionals,’’ they said. “It definitely makes sense for there to be fewer restrictions, because then kids and physicians can figure it out together.’’

Dr. Julia Mason, an Oregon pediatrician who has raised concerns about the increasing numbers of youngsters who are getting transgender treatment, said too many in the field are jumping the gun. She argues there isn’t strong evidence in favor of transgender medical treatment for kids.

“In medicine ... the treatment has to be proven safe and effective before we can start recommending it,’’ Mason said.

Experts say the most rigorous research — studies comparing treated kids with outcomes in untreated kids — would be unethical and psychologically harmful to the untreated group.

The new guidelines include starting medication called puberty blockers in the early stages of puberty, which for girls is around ages 8 to 13 and typically two years later for boys. That’s no change from the group’s previous guidance. The drugs delay puberty and give kids time to decide about additional treatment; their effects end when the medication is stopped.

The blockers can weaken bones, and starting them too young in children assigned males at birth might impair sexual function in adulthood, although long-term evidence is lacking.

The update also recommends:

—Sex hormones — estrogen or testosterone — starting at age 14. This is often lifelong treatment. Long-term risks may include infertility and weight gain, along with strokes in trans women and high blood pressure in trans men, the guidelines say.

—Breast removal for trans boys at age 15. Previous guidance suggested this could be done at least a year after hormones, around age 17, although a specific minimum ag wasn’t listed.

—Most genital surgeries starting at age 17, including womb and testicle removal, a year earlier than previous guidance.

The Endocrine Society, another group that offers guidance on transgender treatment, generally recommends starting a year or two later, although it recently moved to start updating its own guidelines. The American Academy of Pediatrics and the American Medical Association support allowing kids to seek transgender medical treatment, but they don’t offer age-specific guidance.

Dr. Joel Frader, a Northwestern University a pediatrician and medical ethicist who advises a gender treatment program at Chicago’s Lurie Children’s Hospital, said guidelines should rely on psychological readiness, not age.

Frader said brain science shows that kids are able to make logical decisions by around age 14, but they’re prone to risk-taking and they take into account long-term consequences of their actions only when they’re much older.

Coleen Williams, a psychologist at Boston Children’s Hospital’s Gender Multispecialty Service, said treatment decisions there are collaborative and individualized.

“Medical intervention in any realm is not a one-size-fits-all option,” Williams said.

Follow AP Medical Writer Lindsey Tanner at @LindseyTanner.

The Associated Press Health and Science Department receives support from the Howard Hughes Medical Institute’s Department of Science Education. The AP is solely responsible for all content.

• Share full article

Advertisement

Supported by

More Trans Teens Are Choosing ‘Top Surgery’

Small studies suggest that breast removal surgery improves transgender teenagers’ well-being, but data is sparse. Some state leaders oppose such procedures for minors.

By Azeen Ghorayshi

Listen to This Article

Michael, 17, arrived in the sleek white waiting room of his plastic surgeon’s office in Miami for a moment he had long anticipated: removing the bandages to see his newly flat chest.

After years of squeezing into compression undershirts to conceal his breasts, the teenager was overcome with relief that morning last December. Wearing an unbuttoned shirt, he posed for photos with his mother and the surgeon, Dr. Sidhbh Gallagher, happy to share his bare chest with the doctor’s large following on social media.

“It just felt right — like I’d never had breasts in the first place,” Michael said. “It was a ‘Yes, finally’ kind of moment.”

Michael is part of a very small but growing group of transgender adolescents who have had top surgery, or breast removal, to better align their bodies with their experience of gender. Most of these teenagers have also taken testosterone and changed their name, pronouns or clothing style.

Few groups of young people have received as much attention. Republican elected officials across the United States are seeking to ban all so-called gender-affirming care for minors, turning an intensely personal medical decision into a political maelstrom with significant consequences for transgender adolescents and their families.

Gender-related surgeries, in particular, have been thrust into the spotlight. Arizona and Alabama passed laws this year making it illegal for doctors to perform gender-related surgeries on transgender patients under 18. Conservative commentators with large followings on social media have recently targeted children’s hospitals that offer gender surgeries, leading to online harassment and bomb threats .

We are having trouble retrieving the article content.

Please enable JavaScript in your browser settings.

Thank you for your patience while we verify access. If you are in Reader mode please exit and  log into  your Times account, or  subscribe  for all of The Times.

Thank you for your patience while we verify access.

Already a subscriber?  Log in .

Want all of The Times?  Subscribe .

Call us today to discuss cosmetic surgery options to enhance your enjoyment of life

Alameda: 510-864-1800

Brentwood: 925-240-8775

Text Us: 510.650.0383

Gender Reassignment Surgery

Gender reassignment Female-to-Male Breast Surgery

Gender dysphoria occurs in 0.3% of the population. The female-to-male (FTM) gender reassignment surgery in our Alameda and Brentwood practice involves removing both breasts: termed mastectomy, with preservation of the nipple areola complex and with the creation of a contoured, male-looking chest.

• First Name *
• Last Name *
• Procedure of Interest * Procedure of Interest Breast Surgery Gender Reassignment Surgery Male Breast Reduction Arm Lift Surgery Chin Augmentation Slit & Torn Earlobe Repair Eyelid & Eyebrow Lift Facelift Fat Grafting Lip Augmentation Liposuction Otoplasty Post-Bariatric Surgery Rhinoplasty Thigh Lift Tummy Tuck Pediatric Plastic Surgery Reconstruction Skin Treatments Injectables

BRENTWOOD OFFICE

Quick Links

Breast Surgery

Cosmetic Surgery

Pediatric Plastic Surgery

Reconstruction

Skin Treatments

Meet the Team

Surgical Care

Accessibility Statement

Read Patient Reviews »

Alameda Location:

2070 Clinton Ave, Alameda, CA 94501

510-864-1800.

Brentwood Location

1280 Central Blvd, Suite J-5, Brentwood, CA 94513

925-240-8775.

• Type 2 Diabetes
• Heart Disease
• Digestive Health
• Multiple Sclerosis
• Diet & Nutrition
• Health Insurance
• Public Health
• Patient Rights
• Caregivers & Loved Ones
• End of Life Concerns
• Health News
• Thyroid Test Analyzer
• Doctor Discussion Guides
• Hemoglobin A1c Test Analyzer
• Lipid Test Analyzer
• Complete Blood Count (CBC) Analyzer
• What to Buy
• Editorial Process
• Meet Our Medical Expert Board

Gender Confirmation Surgery (GCS)

What is Gender Confirmation Surgery?

• Transfeminine Tr

Transmasculine Transition

• Traveling Abroad

Choosing a Surgeon

Gender confirmation surgery (GCS), known clinically as genitoplasty, are procedures that surgically confirm a person's gender by altering the genitalia and other physical features to align with their desired physical characteristics. Gender confirmation surgeries are also called gender affirmation procedures. These are both respectful terms.

Gender dysphoria , an experience of misalignment between gender and sex, is becoming more widely diagnosed.  People diagnosed with gender dysphoria are often referred to as "transgender," though one does not necessarily need to experience gender dysphoria to be a member of the transgender community. It is important to note there is controversy around the gender dysphoria diagnosis. Many disapprove of it, noting that the diagnosis suggests that being transgender is an illness.

Ellen Lindner / Verywell

Transfeminine Transition

Transfeminine is a term inclusive of trans women and non-binary trans people assigned male at birth.

Gender confirmation procedures that a transfeminine person may undergo include:

• Penectomy is the surgical removal of external male genitalia.
• Orchiectomy is the surgical removal of the testes.
• Vaginoplasty is the surgical creation of a vagina.
• Feminizing genitoplasty creates internal female genitalia.
• Breast implants create breasts.
• Gluteoplasty increases buttock volume.
• Chondrolaryngoplasty is a procedure on the throat that can minimize the appearance of Adam's apple .

Feminizing hormones are commonly used for at least 12 months prior to breast augmentation to maximize breast growth and achieve a better surgical outcome. They are also often used for approximately 12 months prior to feminizing genital surgeries.

Facial feminization surgery (FFS) is often done to soften the lines of the face. FFS can include softening the brow line, rhinoplasty (nose job), smoothing the jaw and forehead, and altering the cheekbones. Each person is unique and the procedures that are done are based on the individual's need and budget,

Transmasculine is a term inclusive of trans men and non-binary trans people assigned female at birth.

Gender confirmation procedures that a transmasculine person may undergo include:

• Masculinizing genitoplasty is the surgical creation of external genitalia. This procedure uses the tissue of the labia to create a penis.
• Phalloplasty is the surgical construction of a penis using a skin graft from the forearm, thigh, or upper back.
• Metoidioplasty is the creation of a penis from the hormonally enlarged clitoris.
• Scrotoplasty is the creation of a scrotum.

Procedures that change the genitalia are performed with other procedures, which may be extensive.

The change to a masculine appearance may also include hormone therapy with testosterone, a mastectomy (surgical removal of the breasts), hysterectomy (surgical removal of the uterus), and perhaps additional cosmetic procedures intended to masculinize the appearance.

Paying For Gender Confirmation Surgery

Medicare and some health insurance providers in the United States may cover a portion of the cost of gender confirmation surgery.

It is unlawful to discriminate or withhold healthcare based on sex or gender. However, many plans do have exclusions.

For most transgender individuals, the burden of financing the procedure(s) is the main difficulty in obtaining treatment. The cost of transitioning can often exceed $100,000 in the United States, depending upon the procedures needed.

A typical genitoplasty alone averages about $18,000. Rhinoplasty, or a nose job, averaged $5,409 in 2019.  

Traveling Abroad for GCS

Some patients seek gender confirmation surgery overseas, as the procedures can be less expensive in some other countries. It is important to remember that traveling to a foreign country for surgery, also known as surgery tourism, can be very risky.

Regardless of where the surgery will be performed, it is essential that your surgeon is skilled in the procedure being performed and that your surgery will be performed in a reputable facility that offers high-quality care.

When choosing a surgeon , it is important to do your research, whether the surgery is performed in the U.S. or elsewhere. Talk to people who have already had the procedure and ask about their experience and their surgeon.

Before and after photos don't tell the whole story, and can easily be altered, so consider asking for a patient reference with whom you can speak.

It is important to remember that surgeons have specialties and to stick with your surgeon's specialty. For example, you may choose to have one surgeon perform a genitoplasty, but another to perform facial surgeries. This may result in more expenses, but it can result in a better outcome.

A Word From Verywell

Gender confirmation surgery is very complex, and the procedures that one person needs to achieve their desired result can be very different from what another person wants.

Each individual's goals for their appearance will be different. For example, one individual may feel strongly that breast implants are essential to having a desirable and feminine appearance, while a different person may not feel that breast size is a concern. A personalized approach is essential to satisfaction because personal appearance is so highly individualized.

Davy Z, Toze M. What is gender dysphoria? A critical systematic narrative review . Transgend Health . 2018;3(1):159-169. doi:10.1089/trgh.2018.0014

Morrison SD, Vyas KS, Motakef S, et al. Facial Feminization: Systematic Review of the Literature . Plast Reconstr Surg. 2016;137(6):1759-70. doi:10.1097/PRS.0000000000002171

Hadj-moussa M, Agarwal S, Ohl DA, Kuzon WM. Masculinizing Genital Gender Confirmation Surgery . Sex Med Rev . 2019;7(1):141-155. doi:10.1016/j.sxmr.2018.06.004

Dowshen NL, Christensen J, Gruschow SM. Health Insurance Coverage of Recommended Gender-Affirming Health Care Services for Transgender Youth: Shopping Online for Coverage Information . Transgend Health . 2019;4(1):131-135. doi:10.1089/trgh.2018.0055

American Society of Plastic Surgeons. Rhinoplasty nose surgery .

Rights Group: More U.S. Companies Covering Cost of Gender Reassignment Surgery. CNS News. http://cnsnews.com/news/article/rights-group-more-us-companies-covering-cost-gender-reassignment-surgery

The Sex Change Capital of the US. CBS News. http://www.cbsnews.com/2100-3445_162-4423154.html

By Jennifer Whitlock, RN, MSN, FN Jennifer Whitlock, RN, MSN, FNP-C, is a board-certified family nurse practitioner. She has experience in primary care and hospital medicine.

Female-to-Male Top Surgery Cost & Procedure Information

The  female-to-male transsexual  in Atlanta often desires an aesthetically pleasing male chest as his first and arguably most important surgical procedure to continue the gender transition. This Female-to-Male (FTM) or gender reassignment surgery (GRS) allows the patient to live more easily in the male gender role and facilitates a real-life experience. Top Surgery includes bilateral mastectomy (removal of the breasts) and male chest contouring and is one of the most frequent female to male surgeries performed. Top Surgery is also sometimes referred to as male chest reconstruction or simply, chest surgery. The female to male breast removal surgery removes almost all of the breast tissue and greatly reduces, almost eliminating, the possibility of developing breast cancer. Mammograms are no longer recommended after he transitions FTM. We perform gender transition surgery for patients in Atlanta and surrounding suburbs near Marietta, Cumming, Kennesaw, and Alpharetta.

Request A Consultation

Click Here to Visit our Trans Top Surgery Center's Website to Learn More!

Female-to-Male Transition Top Surgery

The female-to-male breast surgery is known as a subcutaneous mastectomy and there are several techniques that are used. The patient's breast size and body build determine which technique is ideal for him. On occasion, when breasts are so large as to cause severe and incapacitating back, neck, and shoulder pain, the breast reduction procedure may be a covered service by your insurance policy. We can help you determine if you have these benefits in your plan.

For some doctors performing the female to male transition surgery, the mastectomy is done in two steps, first, the contents of the breast are removed. The surgeon removes the contents through either a cut inside the areola or around it, and then let the skin retract for about a year. After a year the second surgery removes the excess skin. This technique results in far less scarring, and the nipple-areola doesn't need to be removed and grafted. I have developed my own unique female to male breast augmentation procedure because the existing procedures didn't fully address the needs of my patient. It is called the "Comma Procedure" because of the shape of the surgical scar resembles a comma. I take each and every individual's needs and unique attributes into consideration when planning out their procedure to make sure their gender transition surgery goes beyond their expectations. 

Male-to-Female Transition Top Surgery

The  male-to-female transsexual in Atlanta   generally has worn external breast prostheses for several years prior to making a decision to have breast augmentation surgery. She has developed a very accurate image of the size breast that looks best on her body which makes the decision of choosing the proper implant size much easier than for the usual small-breasted woman requesting breast augmentation.

We provide breast augmentation surgery  as well for the MTF transition. During your initial consultation, Dr. Lincenberg will review your medical history and answer any questions you may have. You will need to make decisions on breast size (cup size), on the type and shape of implants you will receive, and on the location of your incisions. Dr. Lincenberg will ask you for your personal preferences so he can recommend the right implant size and shape for you. You will also be able to try on breast implant sizers to help you with your decision on breast augmentation surgery.

You may choose either silicone or saline implants. Silicone implants are made from a gel that holds together uniformly while retaining the natural give that resembles breast tissue. Saline implants are filled with a saltwater solution similar to the fluid that makes up most of the human body and has a slightly firmer feel.

Male-to-Neutrois Top Surgery

MTN or Male to Neutrois transition refers to individuals who have been identified at birth to have male genitalia, but whose personal identity falls outside of the binary male gender they've been assigned to. Neutrois is best understood as a non-binary gender that doesn't identify as singularly male or female. Dr. Lincenberg has experience working with individuals to shape their chest to be more gender neutral.

Female-to-Neutrois Top Surgery

FTN or Femail to Neutrois transition refers to individuals who have been identified at birth to have female genitalia. These individual's personal identity falls outside of the binary female gender they've been assigned to. To transition to a non-binary gender, our FTN clients normally want to remove their breasts and shape their chest to be more gender neutral. 

How Much Does A Transgender Mastectomy Cost?

The Mastectomy procedure can cost anywhere from $8400 - $8600. The actual costs will be determined after we understand your individual needs and wants for the procedure. We understand plastic surgery is an investment and want all of our clients to pursue it with as much knowledge as possible.  Schedule a consultation  to meet with Dr. Lincenberg to learn more about the Atlanta plastic surgery procedures you’re interested in and get a specific quote.

Dr. Lincenberg Reviews

"Dr. Lincenberg and his staff are amazing! He is definitely worth every penny. They were all so accepting, they treated us like family. Dr. Lincenberg makes you feel so comfortable and he shares in on the excitement that you feel! He is amazing at what he does!!! I love Dr. Sheldon and his staff." - Kaylyn

"Staff was so friendly and accommodating! Dr. Lincenberg made me feel so at ease about my procedure and I am very happy with the results!!" - Drewlonda

"This the absolute best surgeon in Atlanta! He did an amazing job on my chest! The staff is wonderful and so very personable and helpful. You cannot ask for better service and experience with the staff and doctor! Thanks so much for a new outlook on life! Y’all are awesome!!!" - Lee

"Wonderful experience with both the doctor and staff. It was prompt and every question was answered with professional ease. I would recommend Georgia Plastic Surgery to anyone that was looking for advice." - Caiden

Before and After Gallery

Gender confirmation surgery.

Thank you for visiting nature.com. You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

• View all journals
• Explore content
• About the journal
• Publish with us
• Sign up for alerts
• Review Article
• Published: 12 April 2011

Gender reassignment surgery: an overview

• Gennaro Selvaggi 1 &
• James Bellringer 1  

Nature Reviews Urology volume  8 ,  pages 274–282 ( 2011 ) Cite this article

4001 Accesses

153 Citations

41 Altmetric

Metrics details

• Pathogenesis
• Reconstruction
• Urogenital diseases

This article has been updated

Gender reassignment (which includes psychotherapy, hormonal therapy and surgery) has been demonstrated as the most effective treatment for patients affected by gender dysphoria (or gender identity disorder), in which patients do not recognize their gender (sexual identity) as matching their genetic and sexual characteristics. Gender reassignment surgery is a series of complex surgical procedures (genital and nongenital) performed for the treatment of gender dysphoria. Genital procedures performed for gender dysphoria, such as vaginoplasty, clitorolabioplasty, penectomy and orchidectomy in male-to-female transsexuals, and penile and scrotal reconstruction in female-to-male transsexuals, are the core procedures in gender reassignment surgery. Nongenital procedures, such as breast enlargement, mastectomy, facial feminization surgery, voice surgery, and other masculinization and feminization procedures complete the surgical treatment available. The World Professional Association for Transgender Health currently publishes and reviews guidelines and standards of care for patients affected by gender dysphoria, such as eligibility criteria for surgery. This article presents an overview of the genital and nongenital procedures available for both male-to-female and female-to-male gender reassignment.

The management of gender dysphoria consists of a combination of psychotherapy, hormonal therapy, and surgery

Psychiatric evaluation is essential before gender reassignment surgical procedures are undertaken

Gender reassignment surgery refers to the whole genital, facial and body procedures required to create a feminine or a masculine appearance

Sex reassignment surgery refers to genital procedures, namely vaginoplasty, clitoroplasty, labioplasty, and penile–scrotal reconstruction

In male-to-female gender dysphoria, skin tubes formed from penile or scrotal skin are the standard technique for vaginal construction

In female-to-male gender dysphoria, no technique is recognized as the standard for penile reconstruction; different techniques fulfill patients' requests at different levels, with a variable number of surgical technique-related drawbacks

This is a preview of subscription content, access via your institution

Access options

Subscribe to this journal

Receive 12 print issues and online access

195,33 € per year

only 16,28 € per issue

Buy this article

• Purchase on SpringerLink
• Instant access to full article PDF

Prices may be subject to local taxes which are calculated during checkout

Similar content being viewed by others

Principles and outcomes of gender-affirming vaginoplasty

Sexual function of transgender assigned female at birth seeking gender affirming care: a narrative review

The effect of early puberty suppression on treatment options and outcomes in transgender patients

Change history, 26 april 2011.

In the version of this article initially published online, the statement regarding the frequency of male-to-female transsexuals was incorrect. The error has been corrected for the print, HTML and PDF versions of the article.

Meyer, W. 3rd. et al . The Harry Benjamin International Gender Dysphoria Association's standards of care for gender identity disorders, sixth version. World Professional Association for Transgender Health [online] , (2001).

Google Scholar  

Bakker, A., Van Kesteren, P., Gooren, L. & Bezemer, P. The prevalence of transsexualism in The Netherlands. Acta Psychiatr. Scand. 87 , 237–238 (1993).

Article   CAS   Google Scholar  

Selvaggi, G. et al . Gender identity disorder: general overview and surgical treatment for vaginoplasty in male-to-female transsexuals. Plast. Reconstr. Surg. 116 , 135e–145e (2005).

Article   Google Scholar  

Benjamin, H. (ed.) The Transsexual Phenomenon (Julian Press Inc., New York, 1966).

World Professional Association for Transgender Health [online] , (2010).

Zhou, J. N., Hofman, M. A., Gooren, L. J. & Swaab, D. F. A sex difference in the human brain and its relation to transsexuality. Nature 378 , 68–70 (1995).

Kruijver, F. P. et al . Male-to-female transsexuals have female neuron numbers in a limbic nucleus. J. Clin. Endocrinol. Metab. 85 , 2034–2041 (2000).

Swaab, D. F., Chun, W. C., Kruijver, F. P., Hofman, M. A. & Ishuina, T. A. Sexual differentiation of the human hypothalamus. Adv. Exp. Med. Biol. 511 , 75–105 (2002).

Garcia-Falgueras, A. & Swaab, D. F. A sex difference in the hypothalamic uncinate nucleus: relationship to gender identity. Brain 131 , 3115–3117 (2008).

Cohen-Kettenis, P. & Kuiper, B. Transseksualiteit en psychotherapie [Dutch]. Tijdschr. Psychoth. 3 , 153–166 (1984).

Kuiper, B. & Cohen-Kettenis, P. Sex reassignment surgery: a study of 141 Dutch transsexuals. Arch. Sex. Behav. 17 , 439–457 (1988).

Kanhai, R. C., Hage, J. J., Karim, R. B. & Mulder, J. W. Exceptional presenting conditions and outcome of augmentation mammoplasty in male-to female transsexuals. Ann. Plast. Surg. 43 , 476–483 (1999).

Kanagalingm, J. et al . Cricothyroid approximation and subluxation in 21 male-to-female transsexuals. Laryngoscope 115 , 611–618 (2005).

Bouman, M. Laparoscopic assisted colovaginoplasty. Presented at the 2009 biennial World Professional Association for Transgender Health meeting, Oslo.

Rubin, S. O. Sex-reassignment surgery male-to-female. Review, own results and report of a new technique using the glans penis as a pseudoclitoris. Scand. J. Urol. Nephrol. Suppl. 154 , 1–28 (1993).

CAS   PubMed   Google Scholar  

Fang, R. H., Chen, C. F. & Ma, S. A new method for clitoroplasty in male-to-female sex reassignment surgery. Plast. Reconstr. Surg. 89 , 679–682 (1992).

Selvaggi, G. et al . Genital sensitivity in sex reassignment surgery. Ann. Plast. Surg. 58 , 427–433 (2007).

Watanayusakul, S. SRS procedures. The Suporn Clinic [online] , (2010).

Melzer, T. Managing complications of male to female surgery. Presented at the 2007 World Professional Association for Transgender Health biennial meeting, Chicago.

Gilleard, O., Qureshi, M., Thomas, P. & Bellringer, J. Urethral bleeding following male to female gender reassignmetn surgery. Presented at the 2009 World Professional Association for Transgender Health biennial meeting, Oslo.

Beckley, I., Thomas, P. & Bellringer, J. Aetiology and management of recto-vaginal fistulas following male to female gender reassignment. Presented at 2008 EAU section of genitourinary surgeons and the EAU section of andrological urology meeting, Madrid.

Monstrey, S. et al . Chest wall contouring surgery in female-to-male (FTM) transsexuals: a new algorithm. Plast. Reconstr. Surg. 121 , 849–859 (2008).

Mueller, A. & Gooren, L. Hormone-related tumors in transsexuals receiving treatment with cross-sex hormones. Eur. J. Endocrinol. 159 , 197–202 (2008).

Selvaggi, G., Elander, A. & Branemark, R. Penile epithesis: preliminary study. Plast. Reconstr. Surg. 126 , 265e–266e (2010).

Selvaggi, G. & Elander, A. Penile reconstruction/formation. Curr. Opin. Urol. 18 , 589–597 (2008).

Gilbert, D. A., Jordan, G. H., Devine, C. J. Jr & Winslow, B. H. Microsurgical forearm “cricket bat-transformer” phalloplasty. Plast. Reconstr. Surg. 90 , 711–716 (1992).

Bettocchi, C., Ralph, D. J. & Pryor, J. P. Pedicled pubic phalloplasty in females with gender dysphoria. BJU Int. 95 , 120–124 (2005).

Monstrey, S. et al . Penile reconstruction: is the radial forearm flap really the standard technique? Plast. Reconstr. Surg. 124 , 510–518 (2009).

Selvaggi, G. et al . Donor-site morbidity of the radial forearm free flap after 125 phalloplasties in gender identity disorder. Plast. Reconstr. Surg. 118 , 1171–1177 (2006).

Hoebeke, P. et al . Impact of sex reassignment surgery on lower urinary tract function. Eur. Urol. 47 , 398–402 (2005).

Agrawal, V. & Ralph, D. An audit of implanted penile prosteses in the UK. BJU Int. 98 , 393–395 (2006).

Hoebeke, P. B. et al . Erectile implants in female-to-male transsexuals: our experience in 129 patients. Eur. Urol. 57 , 334–340 (2010).

Vesely, J. et al . New technique of total phalloplasty with reinnervated latissimus dorsi myocutaneous free flap in female-to-male transsexuals. Ann. Plast. Surg. 58 , 544–550 (2007).

Selvaggi, G. et al . Scrotal reconstruction in female-to-male transsexuals: a novel scrotoplasty. Plast. Reconstr. Surg. 123 , 1710–1718 (2009).

Download references

Author information

Authors and affiliations.

Gender Surgery Unit, Charing Cross Hospital, Imperial College NHS Trust, 179–183 Fulham Palace Road, London, W6 8QZ, UK

Gennaro Selvaggi & James Bellringer

You can also search for this author in PubMed   Google Scholar

Contributions

G. Selvaggi and J. Bellringer contributed equally to the research, discussions, writing, reviewing, and editing of this article.

Corresponding author

Correspondence to James Bellringer .

Ethics declarations

Competing interests.

The authors declare no competing financial interests.

Rights and permissions

Reprints and permissions

About this article

Cite this article.

Selvaggi, G., Bellringer, J. Gender reassignment surgery: an overview. Nat Rev Urol 8 , 274–282 (2011). https://doi.org/10.1038/nrurol.2011.46

Download citation

Published : 12 April 2011

Issue Date : May 2011

DOI : https://doi.org/10.1038/nrurol.2011.46

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

This article is cited by

A bibliometric and visualisation analysis on the research of female genital plastic surgery based on the web of science core collection database.

• Xianling Zhang

Aesthetic Plastic Surgery (2024)

Chest Feminization in Transwomen with Subfascial Breast Augmentation—Our Technique and Results

• James Roy Kanjoor
• Temoor Mohammad Khan

Aesthetic Plastic Surgery (2023)

Vaginoplasty in Male to Female transgenders: single center experience and a narrative review

• Luca Ongaro
• Giulio Garaffa
• Giovanni Liguori

International Journal of Impotence Research (2021)

Urethral complications after gender reassignment surgery: a systematic review

• L. R. Doumanian

Overview on metoidioplasty: variants of the technique

• Marta Bizic
• Borko Stojanovic
• Miroslav Djordjevic

Quick links

• Explore articles by subject
• Guide to authors
• Editorial policies

Sign up for the Nature Briefing newsletter — what matters in science, free to your inbox daily.

Gender Affirming Surgery

• Clinical Policy Bulletins
• Medical Clinical Policy Bulletins

Number: 0615

Table Of Contents

--> This Clinical Policy Bulletin addresses gender affirming surgery.  : Some plans may cover gender affirming procedures in addition to the following policy. Please check the specific benefit plan documents. Aetna considers gender affirming surgery medically necessary when criteria for each of the following procedures is met: ) assessing the transgender/gender diverse individual’s readiness for physical treatment; ); ) assessing the transgender/gender diverse individual’s readiness for physical treatments;  );  ) assessing the transgender/gender diverse individual’s readiness for physical treatments; ); ) assessing the transgender/gender diverse individual’s readiness for physical treatments; ); Gender-specific services may be medically necessary for transgender persons appropriate to their anatomy.  Examples include: Aetna considers reversal of gender affirming surgery (performing surgical procedures to return anatomy to that of the sex assigned at birth) medically necessary for persons who regret their gender-related surgical intervention, where applicable requirements for gender affirming surgery listed above are met. Aetna considers gonadotropin-releasing hormone medically necessary to suppress puberty in trans identified adolescents if they meet World Professional Association for Transgender Health (WPATH) criteria (see ). Aetna considers more than one breast augmentation not medically necessary. This does not include the medically necessary replacement of breast implants (see ). Aetna considers the following procedures that may be performed as a component of a gender transition as not medically necessary and cosmetic (not an all-inclusive list) (see also ): --> --> Table: Code Code Description : 13131 Repair, complex, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; 1.1 cm to 2.5 cm 13132 Repair, complex, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; 2.6 cm to 7.5 cm 13133 Repair, complex, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; each additional 5 cm or less 13160 Secondary closure of surgical wound or dehiscence, extensive or complicated 14021 Adjacent tissue transfer or rearrangement, scalp, arms and/or legs; defect 10.1 sq cm to 30.0 sq cm 14040 Adjacent tissue transfer or rearrangement, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; defect 10 sq cm or less 14041 Adjacent tissue transfer or rearrangement, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; defect 10.1 sq cm to 30.0 sq cm 14301 Adjacent tissue transfer or rearrangement, any area; defect 30.1 sq cm to 60.0 sq cm 14302 Adjacent tissue transfer or rearrangement, any area; each additional 30.0 sq cm, or part thereof 15002 -15003 Surgical preparation or creation of recipient site by excision of open wounds, burn eschar, or scar (including subcutaneous tissues), or incisional release of scar contracture, trunk, arms, legs; first 100 sq cm or 1% of body area of infants and children. + each additional 15004 Surgical preparation or creation of recipient site by excision of open wounds, burn eschar, or scar (including subcutaneous tissues), or incisional release of scar contracture, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet and/or multiple digits; first 100 sq cm or 1% of body area of infants and children 15100 - 15101 Split-thickness autograft, trunk, arms, legs; first 100 sq cm or less, or 1% of body area of infants and children + each additional 1% 15115 Epidermal autograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; first 100 sq cm or less, or 1% of body area of infants and children 15120 Split-thickness autograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; first 100 sq cm or less, or 1% of body area of infants and children 15240 - 15241 Full thickness graft, free, including direct closure of donor site, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands, and/or feet; 20 sq cm or less. + each additional 15273 -15274 Application of skin substitute graft to trunk, arms, legs, total wound surface area greater than or equal to 100 sq cm; first 100 sq cm wound surface area, or 1% of body area of infants and children + each additional 1% 15275 Application of skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, total wound surface area up to 100 sq cm; first 25 sq cm or less wound surface area 15277 - 15278 Application of skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, total wound surface area greater than or equal to 100 sq cm; first 100 sq cm wound surface area, or 1% of body area of infants and children. + each additional 1% 15574 Formation of direct or tubed pedicle, with or without transfer; forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands or feet 15734 Muscle, myocutaneous, or fasciocutaneous flap; trunk 15738 Muscle, myocutaneous, or fasciocutaneous flap; lower extremity 15740 Flap; island pedicle requiring identification and dissection of an anatomically named axial vessel 15750 Flap; neurovascular pedicle 15757 Free skin flap with microvascular anastomosis 15771 Grafting of autologous fat harvested by liposuction technique to trunk, breasts, scalp, arms, and/or legs; 50 cc or less injectate [covered for breast augmentation only] 15772 Grafting of autologous fat harvested by liposuction technique to trunk, breasts, scalp, arms, and/or legs; each additional 50 cc injectate, or part thereof (List separately in addition to code for primary procedure) [covered for breast augmentation only] 15773 Grafting of autologous fat harvested by liposuction technique to face, eyelids, mouth, neck, ears, orbits, genitalia, hands, and/or feet; 25 cc or less injectate 15860 Intravenous injection of agent (eg, fluorescein) to test vascular flow in flap or graft 17380 Electrolysis epilation, each 30 minutes [Check benefits] 17999 Unlisted procedure, skin, mucous membrane and subcutaneous tissue [laser hair removal] [Check benefits] 19318 Reduction mammaplasty 19325 Breast augmentation with implant 19350 Nipple/areola reconstruction [only covered when not performed at time of original breast surgery] 19357 Tissue expander placement in breast reconstruction, including sub sequent expansion(s) can be authorized for gender affirmation coverage 40808 Biopsy, vestibule of mouth 40818 Excision of mucosa of vestibule of mouth as donor graft 49329 Unlisted laparoscopy procedure, abdomen, peritoneum and omentum [graft from colon for vaginoplasty] 51040 Cystostomy, cystotomy with drainage 51102 Aspiration of bladder; with insertion of suprapubic catheter 52005 Cystourethroscopy, with ureteral catheterization, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service 53400 Urethroplasty; first stage, for fistula, diverticulum, or stricture (eg, Johannsen type) 53405 Urethroplasty; second stage (formation of urethra), including urinary diversion 53410 Urethroplasty, 1-stage reconstruction of male anterior urethra 53430 Urethroplasty, reconstruction of female urethra 53520 Closure of urethrostomy or urethrocutaneous fistula, male (separate procedure) 54120 Amputation of penis; partial 54125 Amputation of penis; complete 54235 Injection of corpora cavernosa with pharmacologic agent(s) (eg, papaverine, phentolamine) 54300 Plastic operation of penis for straightening of chordee (eg, hypospadias), with or without mobilization of urethra 54304 Plastic operation on penis for correction of chordee or for first stage hypospadias repair with or without transplantation of prepuce and/or skin flaps 54336 1-stage perineal hypospadias repair requiring extensive dissection to correct chordee and urethroplasty by use of skin graft tube and/or island flap 54400 - 54417 Penile prosthesis 54520 Orchiectomy, simple (including subcapsular), with or without testicular prosthesis, scrotal or inguinal approach 54660 Insertion of testicular prosthesis (separate procedure) 55150 Resection of scrotum 55175 Scrotoplasty; simple 55180     complicated 55970 Intersex surgery; male to female [a series of staged procedures that includes male genitalia removal, penile dissection, urethral transposition, creation of vagina and labia with stent placement] 55980     female to male [a series of staged procedures that include penis and scrotum formation by graft, and prostheses placement] 56625 Vulvectomy simple; complete 56800 Plastic repair of introitus 56805 Clitoroplasty for intersex state 56810 Perineoplasty, repair of perineum, nonobstetrical (separate procedure) 57106, 57110 Vaginectomy, partial removal of vaginal wall, or complete removal of vaginal wall 57282 Colpopexy, vaginal; extra-peritoneal approach (sacrospinous, iliococcygeus) 57291 - 57292 Construction of artificial vagina 57335 Vaginoplasty for intersex state 57425 Laparoscopy, surgical, colpopexy (suspension of vaginal apex) 58150, 58180, 58260 - 58262, 58275 - 58291, 58541 - 58544, 58550 - 58554 Hysterectomy 58570 - 58573 Laparoscopy, surgical, with total hysterectomy 58661 Laparoscopy, surgical; with removal of adnexal structures (partial or total oophorectomy and/or salpingectomy) 58720 Salpingo-oophorectomy, complete or partial, unilateral or bilateral 58999 Unlisted procedure, female genital system (nonobstetrical) [metoidioplasty] 64708 Neuroplasty, major peripheral nerve, arm or leg, open; other than specified 64856 Suture of major peripheral nerve, arm or leg, except sciatic; including transposition 64859 Suture of each additional major peripheral nerve 64874 Suture of nerve; requiring extensive mobilization, or transposition of nerve 64910 Nerve repair; with synthetic conduit or vein allograft (eg, nerve tube), each nerve : 11950 - 11954 Subcutaneous injection of filling material (e.g., collagen) 15200 Full thickness graft, free, including direct closure of donor site, trunk; 20 sq cm or less [nipple reconstruction] 15775 Punch graft for hair transplant; 1 to 15 punch grafts 15776 Punch graft for hair transplant; more than 15 punch grafts 15780 - 15787 Dermabrasion 15788 - 15793 Chemical peel 15820 - 15823 Blepharoplasty 15824 - 15828 Rhytidectomy [face-lifting] 15830 - 15839 Excision, excessive skin and subcutaneous tissue (includes lipectomy); abdomen, infraumbilical panniculectomy 15876 - 15879 Suction assisted lipectomy 17380 Electrolysis epilation, each 30 minutes 19301 Mastectomy, partial (eg, lumpectomy, tylectomy, quadrantectomy, segmentectomy) 19303 Mastectomy, simple, complete 19316 Mastopexy 19340 Immediate insertion of breast prosthesis following mastopexy, mastectomy or in reconstruction 19342 Delayed insertion of breast prosthesis following mastopexy, mastectomy or in reconstruction 20999 Unlisted procedure, musculoskeletal system, general [unlisted augmentation] [check benefits] 21087 Nasal prosthesis 21120 - 21123 Genioplasty 21125 - 21127 Augmentation, mandibular body or angle; prosthetic material or with bone graft, onlay or interpositional (includes obtaining autograft) 21193 Reconstruction of mandibular rami, horizontal, vertical, C, or L osteotomy; without bone graft 21194     with bone graft (includes obtaining graft) 21195 Reconstruction of mandibular rami and/or body, sagittal split; without internal rigid fixation 21196     with internal rigid fixation 21208 Osteoplasty, facial bones; augmentation (autograft, allograft, or prosthetic implant) 21210 Graft, bone; nasal, maxillary or malar areas (includes obtaining graft) 21270 Malar augmentation, prosthetic material 30400 - 30420 Rhinoplasty; primary 30430 - 30450 Rhinoplasty; secondary 31599 Unlisted procedure, larynx [thyroid chondroplasty and tracheal shave] [voice modification surgery] [check benefits] 31899 Unlisted procedure, trachea, bronchi [thyroid chondroplasty and tracheal shave] [augmentation thyroid chondroplasty (thyroid cartilage augmentation)] [check benefits] 40799 Unlisted procedure, lips [lip shortening] [check benefits] 67900 Repair of brow ptosis (supraciliary, mid-forehead or coronal approach) 92507 Treatment of speech, language, voice, communication, and/or auditory processing disorder; individual 92508 Treatment of speech, language, voice, communication, and/or auditory processing disorder; group, two or more individuals : 11980 Subcutaneous hormone pellet implantation (implantation of estradiol and/or testosterone pellets beneath the skin) +90785 Interactive complexity (List separately in addition to the code for primary procedure) 90832 - 90838 Psychotherapy 96372 Therapeutic, prophylactic, or diagnostic injection (specify substance of drug); subcutaneous or intramuscular : C1789 Prosthesis, breast (implantable) C1813 Prosthesis, penile, inflatable C2622 Prosthesis, penile, non-inflatable J1071 Injection, testosterone cypionate, 1 mg J3121 Injection, testosterone enanthate, 1 mg J3145 Injection, testosterone undecanoate, 1 mg J1950 Injection, leuprolide acetate (for depot suspension), per 3.75 mg J9202 Goserelin acetate implant, per 3.6 mg J9217 Leuprolide acetate (for depot suspension), 7.5 mg J9218 Leuprolide acetate, per 1 mg J9219 Leuprolide acetate implant, 65 mg L8600 Implantable breast prosthesis, silicone or equal S0189 Testosterone pellet, 75 mg : G0153 Services performed by a qualified speech-language pathologist in the home health or hospice setting, each 15 minutes L8499 Unlisted procedure for miscellaneous prosthetic services [prosthetic implant] [check benefits] L8699 Prosthetic implant, not otherwise specified [check benefits] S9128 Speech therapy, in the home, per diem : F64.0 - F64.9 Gender identity disorders Z87.890 Personal history of sex reassignment The International Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10) and the Diagnostic and Statistical Manual of Mental Disorders, (DSM-5-TR) are the diagnostic classifications and criteria manuals used in the United States.  Notwithstanding, the World Professional Association of Transgender Health Standard of Care 8th edition (WPATH SOC8) states: “While Gender Dysphoria (GD) is still considered a mental health condition in the Diagnostic and Statistical Manual of Mental Disorders, (DSM-5-TR) of the American Psychiatric Association. Gender incongruence is no longer seen as pathological or a mental disorder in the world health community. Gender Incongruence is recognized as a condition in the International Classification of Diseases and Related Health Problems, 11th Version of the World Health Organization (ICD-11). Because of historical and current stigma, TGD people can experience distress or dysphoria that may be addressed with various gender-affirming treatment options. While nomenclature is subject to change and new terminology and classifications may be adopted by various health organizations or administrative bodies, the medical necessity of treatment and care is clearly recognized for the many people who experience dissonance between their sex assigned at birth and their gender identity.” Gender dysphoria refers to discomfort or distress that is caused by a discrepancy between an individual’s gender identity and the gender assigned at birth (and the associated gender role and/or primary and secondary sex characteristics). A diagnosis of gender dysphoria requires a marked difference between the individual’s expressed/experienced gender and the gender others would assign him or her, and it must continue for at least six months. This condition may cause clinically significant distress or impairment in social, occupational or other important areas of functioning.   Gender affirming surgery is performed to change primary and/or secondary sex characteristics. For transfeminine (assigned male at birth) gender transition, surgical procedures may include genital reconstruction (vaginoplasty, penectomy, orchidectomy, clitoroplasty), breast augmentation (implants, lipofilling), and cosmetic surgery (facial reshaping, rhinoplasty, abdominoplasty, thyroid chondroplasty (laryngeal shaving), voice modification surgery (vocal cord shortening), hair transplants) (Day, 2002). For transmasculine (assigned female at birth) gender transition, surgical procedures may include mastectomy, genital reconstruction (phalloplasty, genitoplasty, hysterectomy, bilateral oophorectomy), mastectomy, and cosmetic procedures to enhance male features such as pectoral implants and chest wall recontouring (Day, 2002). The criterion noted above for some types of genital surgeries is based on expert clinical consensus that this experience provides ample opportunity for patients to experience and socially adjust in their desired gender role, before undergoing irreversible surgery (Coleman, et al., 2022).  It is recommended that transfeminine persons undergo feminizing hormone therapy (minimum 6 months) prior to breast augmentation surgery. The purpose is to maximize breast growth in order to obtain better surgical (aesthetic) results. In addition to hormone therapy and gender affirming surgery, psychological adjustments are necessary in affirming sex. Treatment should focus on psychological adjustment, with hormone therapy and gender affirming surgery being viewed as confirmatory procedures dependent on adequate psychological adjustment. Mental health care may need to be continued after gender affirming surgery. The overall success of treatment depends partly on the technical success of the surgery, but more crucially on the psychological adjustment of the trans identified person and the support from family, friends, employers and the medical profession. Nakatsuka (2012) noted that the third versions of the guideline for treatment of people with gender dysphoria (GD) of the Japanese Society of Psychiatry and Neurology recommends that feminizing/masculinizing hormone therapy and genital surgery should not be carried out until 18 years old and 20 years old, respectively.  On the other hand, the sixth (2001) and the seventh (2011) versions of the standards of care for the health of transsexual, transgender, and gender non-conforming people of World Professional Association for Transgender Health (WPATH) recommend that transgender adolescents (Tanner stage 2, [mainly 12 to 13 years of age]) are treated by the endocrinologists to suppress puberty with gonadotropin-releasing hormone (GnRH) agonists until age 16 years old, after which gender-affirming hormones may be given.  A questionnaire on 181 people with GID diagnosed in the Okayama University Hospital (Japan) showed that female to male (FTM) trans identified individuals hoped to begin masculinizing hormone therapy at age of 15.6 +/- 4.0 (mean +/- S.D.) whereas male to female (MTF) trans identified individuals hoped to begin feminizing hormone therapy as early as age 12.5 +/- 4.0, before presenting secondary sex characters.  After confirmation of strong and persistent trans gender identification, adolescents with GD should be treated with gender-affirming hormone or puberty-delaying hormone to prevent developing undesired sex characters.  These treatments may prevent transgender adolescents from attempting suicide, suffering from depression, and refusing to attend school.  Spack (2013) stated that GD is poorly understood from both mechanistic and clinical standpoints.  Awareness of the condition appears to be increasing, probably because of greater societal acceptance and available hormonal treatment.  Therapeutic options include hormone and surgical treatments but may be limited by insurance coverage because costs are high.  For patients seeking MTF affirmation, hormone treatment includes estrogens, finasteride, spironolactone, and GnRH analogs.  Surgical options include feminizing genital and facial surgery, breast augmentation, and various fat transplantations.  For patients seeking a FTM gender affirmation, medical therapy includes testosterone and GnRH analogs and surgical therapy includes mammoplasty and phalloplasty.  Medical therapy for both FTM and MTF can be started in early puberty, although long-term effects are not known.  All patients considering treatment need counseling and medical monitoring. Leinung and colleagues (2013) noted that the Endocrine Society's recently published clinical practice guidelines for the treatment of transgender persons acknowledged the need for further information on transgender health.  These investigators reported the experience of one provider with the endocrine treatment of transgender persons over the past 2 decades. Data on demographics, clinical response to treatment, and psychosocial status were collected on all transgender persons receiving gender-affirming hormone therapy since 1991 at the endocrinology clinic at Albany Medical Center, a tertiary care referral center serving upstate New York.  Through 2009, a total 192 MTF and 50 FTM transgender persons were seen.  These patients had a high prevalence of mental health and psychiatric problems (over 50 %), with low rates of employment and high levels of disability.  Mental health and psychiatric problems were inversely correlated with age at presentation.  The prevalence of gender affirming surgery was low (31 % for MTF).  The number of persons seeking treatment has increased substantially in recent years.  Gender-affirming hormone therapy achieves very good results in FTM persons and is most successful in MTF persons when initiated at younger ages.  The authors concluded that transgender persons seeking hormonal therapy are being seen with increasing frequency.  The dysphoria present in many transgender persons is associated with significant mood disorders that interfere with successful careers.  They stated that starting therapy at an earlier age may lessen the negative impact on mental health and lead to improved social outcomes. Meyer-Bahlburg (2013) summarized for the practicing endocrinologist the current literature on the psychobiology of the development of gender identity and its variants in individuals with disorders of sex development or with transgenderism.  Gender reassignment remains the treatment of choice for strong and persistent gender dysphoria in both categories, but more research is needed on the short-term and long-term effects of puberty-suppressing medications and cross-sex hormones on brain and behavior. Note on Breast Reduction/Mastectomy and Nipple Reconstruction The CPT codes for mastectomy (CPT codes 19303) are for breast cancer, and are not appropriate to bill for reduction mammaplasty for female to male (transmasculine) gender affirmation surgery. CPT 2020 states that “Mastectomy procedures (with the exception of gynecomastia [19300]) are performed either for treatment or prevention of breast cancer.” CPT 2020 also states that "Code 19303 describes total removal of ipsilateral breast tissue with or without removal of skin and/or nipples (eg, nipple-sparing), for treatment or prevention of breast cancer.” There are important differences between a mastectomy for breast cancer and a mastectomy for gender reassignment. The former requires careful attention to removal of all breast tissue to reduce the risk of cancer. By contrast, careful removal of all breast tissue is not essential in mastectomy for gender reassignment. In mastectomy for gender reassignment, the nipple areola complex typically can be preserved.  Some have tried to justify routinely billing CPT code 19350 for nipple reconstruction at the time of mastectomy for gender reassignment based upon the frequent need to reduce the size of the areola to give it a male appearance. However, the nipple reconstruction as defined by CPT code 19350 describes a much more involved procedure than areola reduction. The typical patient vignette for CPT code 19350, according to the AMA, is as follows: “The patient is measured in the standing position to ensure even balanced position for a location of the nipple and areola graft on the right breast.  Under local anesthesia, a Skate flap is elevated at the site selected for the nipple reconstruction and constructed.  A full-thickness skin graft is taken from the right groin to reconstruct the areola.  The right groin donor site is closed primarily in layers.”   The AMA vignette for CPT code 19318 (reduction mammaplasty) clarifies that this CPT code includes the work that is necessary to reposition and reshape the nipple to create an aesthetically pleasing result, as is necessary in female to male breast reduction. "The physician reduces the size of the breast, removing wedges of skin and breast tissue from a female patient. The physician makes a circular skin incision above the nipple, in the position to which the nipple will be elevated. Another skin incision is made around the circumference of the nipple. Two incisions are made from the circular cut above the nipple to the fold beneath the breast, one on either side of the nipple, creating a keyhole shaped skin and breast incision. Wedges of skin and breast tissue are removed until the desired size is achieved. Bleeding vessels may be ligated or cauterized. The physician elevates the nipple and its pedicle of subcutaneous tissue to its new position and sutures the nipple pedicle with layered closure. The remaining incision is repaired with layered closure" (EncoderPro, 2019). CPT code 19350 does not describe the work that that is being done, because that code describes the actual construction of a new nipple.  Code 19350 is a CCI “incidental to” edit to code 19318, and, accordingly, the services of code 19350 are included in code 19318. Similarly, graft codes, such as code 15200 (full thickness skin graft) and 15877 (liposuction), are CCI “incidental to” edits to code 19318, and, accordingly, the services of graft codes, such as 15200, and liposuction codes, such as 15877, are included in code 19318.  Vulvoplasty Versus Vaginoplasty as Gender-Affirming Genital Surgery for Transgender Women Jiang and colleagues (2018) noted that gender-affirming vaginoplasty aims to create the external female genitalia (vulva) as well as the internal vaginal canal; however, not all patients desire nor can safely undergo vaginal canal creation.  These investigators described the factors influencing patient choice or surgeon recommendation of vulvoplasty (creation of the external appearance of female genitalia without creation of a neovaginal canal) and evaluated the patient's satisfaction with this choice.  Gender-affirming genital surgery consults were reviewed from March 2015 until December 2017, and patients scheduled for or who had completed vulvoplasty were interviewed by telephone.  These investigators reported demographic data and the reasons for choosing vulvoplasty as gender-affirming surgery for patients who either completed or were scheduled for surgery, in addition to patient reports of satisfaction with choice of surgery, satisfaction with the surgery itself, and sexual activity after surgery.  A total of 486 patients were seen in consultation for trans-feminine gender-affirming genital surgery: 396 requested vaginoplasty and 39 patients requested vulvoplasty; 30 Patients either completed or are scheduled for vulvoplasty.  Vulvoplasty patients were older and had higher body mass index (BMI) than those seeking vaginoplasty.  The majority (63 %) of the patients seeking vulvoplasty chose this surgery despite no contraindications to vaginoplasty.  The remaining patients had risk factors leading the surgeon to recommend vulvoplasty.  Of those who completed surgery, 93 % were satisfied with the surgery and their decision for vulvoplasty.  The authors concluded that this was the first study of factors impacting a patient's choice of or a surgeon's recommendation for vulvoplasty over vaginoplasty as gender-affirming genital surgery; it also was the first reported series of patients undergoing vulvoplasty only.  Drawbacks of this study included its retrospective nature, non-validated questions, short-term follow-up, and selection bias in how vulvoplasty was offered.  Vulvoplasty is a form of gender-affirming feminizing surgery that does not involve creation of a neovagina, and it is associated with high satisfaction and low decision regret. Autologous Fibroblast-Seeded Amnion for Reconstruction of Neo-vagina in Transfeminine Reassignment Surgery Seyed-Forootan and colleagues (2018) stated that plastic surgeons have used several methods for the construction of neo-vaginas, including the utilization of penile skin, free skin grafts, small bowel or recto-sigmoid grafts, an amnion graft, and cultured cells.  These researchers compared the results of amnion grafts with amnion seeded with autograft fibroblasts.  Over 8 years, these investigators compared the results of 24 male-to-female transsexual patients retrospectively based on their complications and levels of satisfaction; 16 patients in group A received amnion grafts with fibroblasts, and the patients in group B received only amnion grafts without any additional cellular lining.  The depths, sizes, secretions, and sensations of the vaginas were evaluated.  The patients were monitored for any complications, including over-secretion, stenosis, stricture, fistula formation, infection, and bleeding.  The mean age of group A was 28 ± 4 years and group B was 32 ± 3 years.  Patients were followed-up from 30 months to 8 years (mean of 36 ± 4) after surgery.  The depth of the vaginas for group A was 14 to 16 and 13 to 16 cm for group B.  There was no stenosis in neither group.  The diameter of the vaginal opening was 34 to 38 mm in group A and 33 to 38 cm in group B.  These researchers only had 2 cases of stricture in the neo-vagina in group B, but no stricture was recorded for group A.  All of the patients had good and acceptable sensation in the neo-vagina; 75 % of patients had sexual experience and of those, 93.7 % in group A and 87.5%  in group B expressed satisfaction.  The authors concluded that the creation of a neo-vaginal canal and its lining with allograft amnion and seeded autologous fibroblasts is an effective method for imitating a normal vagina.  The size of neo-vagina, secretion, sensation, and orgasm was good and proper.  More than 93.7 % of patients had satisfaction with sexual intercourse.  They stated that amnion seeded with fibroblasts extracted from the patient's own cells will result in a vagina with the proper size and moisture that can eliminate the need for long-term dilatation.  The constructed vagina has a 2-layer structure and is much more resistant to trauma and laceration.  No cases of stenosis or stricture were recorded.  Level of Evidence = IV.  These preliminary findings need to be validated by well-designed studies. Pitch-Raising Surgery in Transfeminine Persons Van Damme and colleagues (2017) reviewed the evidence of the effectiveness of pitch-raising surgery performed in male-to-female transsexuals.  These investigators carried out a search for studies in PubMed, Web of Science, Science Direct, EBSCOhost, Google Scholar, and the references in retrieved manuscripts, using as keywords "transsexual" or "transgender" combined with terms related to voice surgery.  They included 8 studies using cricothyroid approximation, 6 studies using anterior glottal web formation, and 6 studies using other surgery types or a combination of surgical techniques, leading to 20 studies in total.  Objectively, a substantial rise in post-operative fundamental frequency was identified.  Perceptually, mainly laryngeal web formation appeared risky for decreasing voice quality.  The majority of patients appeared satisfied with the outcome.  However, none of the studies used a control group and randomization process.  The authors concluded that future research needs to investigate long-term effects of pitch-raising surgery using a stronger study design.  Azul and associates (2017) evaluated the currently available discursive and empirical data relating to those aspects of trans-masculine people's vocal situations that are not primarily gender-related, and identified restrictions to voice function that have been observed in this population, and made suggestions for future voice research and clinical practice.  These researchers conducted a comprehensive review of the voice literature.  Publications were identified by searching 6 electronic databases and bibliographies of relevant articles.  A total of 22 publications met inclusion criteria.  Discourses and empirical data were analyzed for factors and practices that impact on voice function and for indications of voice function-related problems in trans-masculine people.  The quality of the evidence was appraised.  The extent and quality of studies investigating trans-masculine people's voice function was found to be limited.  There was mixed evidence to suggest that trans-masculine people might experience restrictions to a range of domains of voice function, including vocal power, vocal control/stability, glottal function, pitch range/variability, vocal endurance, and voice quality.  The authors concluded that more research into the different factors and practices affecting trans-masculine people's voice function that took account of a range of parameters of voice function and considered participants' self-evaluations is needed to establish how functional voice production can be best supported in this population. Facial Feminization Surgery Raffaini and colleagues (2016) stated that gender dysphoria refers to the discomfort and distress that arise from a discrepancy between a person's gender identity and sex assigned at birth.  The treatment plan for gender dysphoria varies and can include psychotherapy, hormone treatment, and gender affirmation surgery, which is, in part, an irreversible change of sexual identity.  Procedures for transformation to the female sex include facial feminization surgery, vaginoplasty, clitoroplasty, and breast augmentation.  Facial feminization surgery can include forehead re-modeling, rhinoplasty, mentoplasty, thyroid chondroplasty, and voice alteration procedures.  These investigators reported patient satisfaction following facial feminization surgery, including outcome measurements after forehead slippage and chin re-modeling.  A total of 33 patients between 19 and 40 years of age were referred for facial feminization surgery between January of 2003 and December of 2013, for a total of 180 procedures.  Surgical outcome was analyzed both subjectively through questionnaires administered to patients and objectively by serial photographs.  Most facial feminization surgery procedures could be safely completed in 6 months, barring complications.  All patients showed excellent cosmetic results and were satisfied with their procedures.  Both frontal and profile views achieved a loss of masculine features.  The authors concluded that patient satisfaction following facial feminization surgery was high; they stated that the reduction of gender dysphoria had psychological and social benefits and significantly affected patient outcome.  The level of evidence of this study was IV. Morrison and associates (2018) noted that facial feminization surgery encompasses a broad range of cranio-maxillofacial surgical procedures designed to change masculine facial features into feminine features.  The surgical principles of facial feminization surgery could be applied to male-to-female transsexuals and anyone desiring feminization of the face.  Although the prevalence of these procedures is difficult to quantify, because of the rising prevalence of transgenderism (approximately 1 in 14,000 men) along with improved insurance coverage for gender-confirming surgery, surgeons versed in techniques, outcomes, and challenges of facial feminization surgery are needed.  These researchers appraised the current facial feminization surgery literature.  They carried out a comprehensive literature search of the Medline, PubMed, and Embase databases was conducted for studies published through October 2014 with multiple search terms related to facial feminization.  Data on techniques, outcomes, complications, and patient satisfaction were collected.  A total of 15 articles were selected and reviewed from the 24 identified, all of which were either retrospective or case series/reports.  Articles covered a variety of facial feminization procedures.  A total of 1,121 patients underwent facial feminization surgery, with 7 complications reported, although many articles did not explicitly comment on complications.  Satisfaction was high, although most studies did not use validated or quantified approaches to address satisfaction.  The authors concluded that facial feminization surgery appeared to be safe and satisfactory for patients.  These researchers stated that further studies are needed to better compare different techniques to more robustly establish best practices; prospective studies and patient-reported outcomes are needed to establish quality-of-life (QOL) outcomes for patients.   In a systematic review, Gorbea et al (2021) provided a portrait of gender affirmation surgery (GAS) insurance coverage across the U.S., with attention to procedures of the head and neck.  State policies on transgender care for Medicaid insurance providers were collected for all 50 states.  Each state's policy on GAS and facial gender affirmation surgery (FGAS) was examined.  The largest medical insurance companies in the U.S. were identified using the National Association of Insurance Commissioners Market Share report.  Policies of the top 49 primary commercial medical insurance companies were examined.  Medicaid policy reviews found that 18 states offer some level of gender-affirming coverage for their patients, but only 3 include FGAS (17 %); 13 states prohibit Medicaid coverage of all transgender surgery, and 19 states have no published gender-affirming medical care coverage policy; 92 % of commercial medical insurance providers had a published policy on GAS coverage.  Genital reconstruction was described as a medically necessary aspect of transgender care in 100 % of the commercial policies reviewed; 93 % discussed coverage of FGAS, but 51 % considered these procedures cosmetic.  Thyroid chondroplasty (20 %) was the most commonly covered FGAS procedure.  Mandibular and frontal bone contouring, rhinoplasty, blepharoplasty, and facial rhytidectomy were each covered by 13 % of the medical policies reviewed.  The authors concluded that while certain surgical aspects of gender-affirming medical care are nearly ubiquitously covered by commercial insurance providers, FGAS is considered cosmetic by most Medicaid and commercial insurance providers.  Level of Evidence = V. Hohman and Teixeira (2022) stated that with respect to gender affirmation procedures for the face, the majority of interventions will occur in patients transitioning from male to female, i.e., transgender women.  While there are slightly more transgender women than transgender men in the population (33 % transgender women, 29 % transgender men, 35 % non-binary, 3 % cross-dressers, according to the USTS), the reason that more females require surgery than males is that testosterone therapy typically produces enough changes in secondary sex characteristics of the face (growth of facial hair, thickening of the skin, increase in frontal bossing, lowering of the voice, etc.) that surgery is not necessary . In some cases, placement of implants or fat transfer can increase volume in the lower 1/3 of the face and contribute to masculinization.  Still, the primary area of focus for facial feminization is generally the upper 1/3.  Feminization of the upper 1/3 of the face often requires several techniques to be applied in combination: The advancement of the hairline, hair transplantation, brow-lifting, and reduction of frontal bossing or "frontal cranioplasty".  While the advancement of a scalp flap, hair transplant, and pretrichial brow-lifting are commonly employed cosmetic surgery interventions, frontal cranioplasty bears special consideration.  Several methods of reducing the brow's prominence are often described as type 1, 2, and 3 frontal cranioplasties.  Type 1 cranioplasty reduces the supra-orbital ridge's protrusion, usually using a drill, including decreasing the thickness of the anterior table of the frontal sinus.  This technique is the simplest, but it is only effective in patients with either a very thick anterior frontal sinus table or an absent pneumatized frontal sinus.  Type 2 cranioplasty involves augmentation of the forehead's convexity using bone cement or methyl methacrylate in addition to a reduction of the supra-orbital ridge with a drill.  Type 3 cranioplasty is advocated by many prominent facial feminization surgeons and consists of removal of the anterior table of the frontal sinus, thinning of the bone flap, and replacement of that bone onto the frontal sinus but in a more recessed position, in addition to a reduction of the remainder of the supra-orbital ridge.  An alternative to removal and recession of the frontal sinus's anterior table is to thin the bone with a drill and then fracture it in a controlled fashion to produce the desired contour, which is also performed routinely by some authors. Forehead Feminization Cranioplasty Eggerstedt and colleagues (2020) stated that forehead feminization cranioplasty (FFC) is an important component of gender-affirming surgery and has become increasingly popular in recent years.  However, there is little objective evidence for the procedure's safety and clinical impact via patient-reported outcome measures (PROMs).  In a systematic review, these researchers determined what complications are observed following FFC, the relative frequency of complications by surgical technique, and what impact the procedure has on patient's QOL.  They carried out database searches in PubMed/Medline, Scopus, CINAHL, Cochrane CENTRAL, Cochrane Database of Systematic Reviews, and PsycINFO.  The search terms included variations of forehead setback/FFC.  Both controlled vocabularies (i.e., MeSH and CINAHL's Suggested Subject Terms) and keywords in the title or abstract fields were searched.  Two independent reviewers screened the titles and abstracts of all articles; and 2 independent surgeon reviewers examined the full text of all included articles, and relevant data points were extracted.  Main outcomes and measures included complications and complication rate observed following FFC.  Additional outcome measures were the approach used, concurrent procedures carried out, and the use and findings of a PROM.  A total of 10 articles describing FFC were included, entailing 673 patients.  The overall pooled complication rate was 1.3 %; PROMs were used in 50 % of studies, with no standardization among studies.  The authors concluded that complications following FFC were rare and infrequently required reoperation.  Moreover, these researchers stated that further studies into standardized and validated PROMs in facial feminization patients are needed.  Level of Evidence = III. Hand Feminization and Masculinization Lee and colleagues (2021) noted that anatomical characteristics that are incongruent with an individual's gender identity can cause significant gender dysphoria.  Hands exhibit prominent dimorphic sexual features, but despite their visibility, there are limited studies examining gender affirming procedures for the hands.  These researchers examined the anatomical features that define feminine and masculine hands, the surgical and non-surgical approaches for feminization and masculinization of the hand; and adapted established aesthetic hand techniques for gender affirming care.  They carried out a comprehensive database search of PubMed, Embase OVID and SCOPUS to identify articles on the characterization of feminine or masculine hands, hand treatments related to gender affirmation, and articles related to techniques for hand feminization and masculinization in the non-transgender population.  From 656 possibly relevant articles, 42 met the inclusion criteria for the current literature search.  There is currently no medical literature specifically examining the surgical or non-surgical options for hand gender affirmation.  The available techniques for gender affirming procedures discussed in this paper were appropriated from those more commonly used for hand rejuvenation.  The authors concluded that there is very little evidence addressing the options for transgender individuals seeking gender affirming procedures of the hand.  These researchers stated that although established procedures used for hand rejuvenation may be employed in gender affirming care, further study is needed to determine relative salience of various hand features to gender dysphoria in transgender patients of various identities, as well as development of novel techniques to meet these needs.  Level of Evidence = III. Peritoneal Pull-Through Technique Vaginoplasty in Neovagina Construction in Gender-Affirming Surgery Tay and Lo (2022) reviewed the application, effectiveness and outcomes of a novel surgical technique, peritoneal pull-through technique vaginoplasty, in gender-affirming surgery.  Specific outcome parameters included healing time, depth of cavity achieved,) alleviation of dysphoria, and morbidity of the surgery.  These researchers carried out a systematic review according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement and PROSPERO registration obtained before commencement.  A search was performed in OVID Medline, Embase, Willey Online Library and PubMed.  Specialty-related journals, grey literature and reference lists of relevant articles were manually searched.  From 476 potentially relevant articles, 12 articles were analyzed; and the publications were all level 4 or level 5 evidence.  Healing times were poorly reported or often not mentioned.  A total of 8 authors reported neovagina cavity depth of at least 13 cm and good patient satisfaction.  Alleviation of dysphoria was not discussed by any of the publications and only 6reported complications.  Average follow-up ranged from 6 weeks to 14.8 months.  The authors concluded that the use of peritoneal pull-through vaginoplasty in gender-affirming surgery is promising and novel; however, there is a paucity of data.  These investigators stated that further research and longer-term data are needed to examine the safety and effectiveness of this technique including stabilization of vaginal depth, later morbidity and complications.  Patients seeking this surgery overseas should be informed of the potential difficulties they may face. Urethral Complications and Outcomes in Transgender Men Hu et al (2022) noted that urologic problems, such as urethral fistulas and strictures, are among the most frequent complications following phalloplasty.  Although many studies have reported successful phalloplasty and urethral reconstruction with reliable outcomes in transgender men; so far, no method has become standardized.  These researchers examined the reports on urological complications and outcomes in transgender men with respect to various types of urethral reconstruction.  They carried out a comprehensive literature search of PubMed, Scopus, and Google Scholar databases for studies related to phalloplasty in transsexuals.  Data on various phallic urethral techniques, urethral complications, and outcomes were collected and analyzed using the random-effects model.  A total of 21 studies (1,566 patients) were included: 8 studies (1,061 patients) on "tube-in-tube", 9 studies (273 patients) on "prelaminated flap,  and 6 studies (221 patients) on "second flap".  Compared with the tube-in-tube technique, the pre-laminated flap was associated with a significantly higher urethral stricture/stenosis rate; however, there was no difference between the pre-laminated flap and the 2nd flap techniques.  For all phalloplasty patients, the pooled rate of urethral fistula or stenosis was 48.9 %, the rate of the ability to void while standing was 91.5 %, occurrence rate of tactile or erogenous sensation was 88 %, the prosthesis complication rate was 27.9 %, and patient-reported satisfactory outcome rate was 90.5 %.  The authors concluded that urethral reconstruction with a pre-laminated flap was associated with a significantly higher urethral stricture rate and increased need of revision surgery compared with that observed using a skin flap.  Overall, most patients were able to void while standing and were satisfied with the outcomes. DSM 5 Criteria for Gender Dysphoria in Adults and Adolescents A marked incongruence between one’s experienced/expressed gender and assigned gender, of at least 6 months duration, as manifested by two or more of the following: A marked incongruence between one’s experienced/expressed gender and primary and/or secondary sex characteristics (or, in young adolescents, the anticipated secondary sex characteristics) A strong desire to be rid of one’s primary and/or secondary sex characteristics because of a marked incongruence with one’s experienced/expressed gender (or, in young adolescents, a desire to prevent the development of the anticipated secondary sex characteristics) A strong desire for the primary and/or secondary sex characteristics of the other gender A strong desire to be of the other gender (or some alternative gender different from one’s assigned gender) A strong desire to be treated as the other gender (or some alternative gender different from one’s assigned gender) A strong conviction that one has the typical feelings and reactions of the other gender (or some alternative gender different from one’s assigned gender). The condition is associated with clinically significant distress or impairment in social, occupational, or other important areas of functioning. There is no minimum duration of relationship required with mental health professional.  It is the professional’s judgment as to the appropriate length of time before a referral letter can appropriately be written.  A common period of time is three months, but there is significant variation in both directions. Evaluation of candidacy for gender affirmation surgery by a mental health professional is covered under the member’s medical benefit, unless the services of a mental health professional are necessary to evaluate and treat a mental health problem, in which case the mental health professional’s services are covered under the member’s behavioral health benefit. Please check benefit plan descriptions. Characteristics of a Qualified Health Professionals (From SOC-8) Qualifications of Mental Health Professional for assessing transgender and gender diverse adults for physical treatments (from WPATH SOC-8): Are licensed by their statutory body and hold, at a minimum, a master’s degree or equivalent training in a clinical field relevant to this role and granted by a nationally accredited statutory institution. Are able to identify co-existing mental health or other psychosocial concerns and distinguish these from gender dysphoria, incongruence, and diversity. Are able to assess capacity to consent for treatment. Have experience or be qualified to assess clinical aspects of gender dysphoria, incongruence, and diversity. Undergo continuing education in health care relating to gender dysphoria, incongruence, and diversity. Liaise with professionals from different disciplines within the field of transgender health for consultation and referral on behalf of gender diverse adults seeking gender-affirming treatment, if required. Credentials of surgeons who perform gender-affirming surgical procedures (fromWPATH SOC-8): Training and documented supervision in gender-affirming procedures; Maintenance of an active practice in gender-affirming surgical procedures; Knowledge about gender diverse identities and expressions; Continuing education in the field of gender-affirmation surgery; Tracking of surgical outcomes. Characteristics of health care professionals working with gender diverse adolescents: Are licensed by their statutory body and hold a postgraduate degree or its equivalent in a clinical field relevant to this role granted by a nationally accredited statutory institution. Receive theoretical and evidenced-based training and develop expertise in general child, adolescent, and family mental health across the developmental spectrum. Receive training and have expertise in gender identity development, gender diversity in children and adolescents, have the ability to assess capacity to assent/consent, and possess general knowledge of gender diversity across the life span. Receive training and develop expertise in autism spectrum disorders and other neurodevelopmental presentations or collaborate with a developmental disability expert when working with autistic/neurodivergent gender diverse adolescents. Continue engaging in professional development in all areas relevant to gender diverse children, adolescents, and families. The above policy is based on the following references: Almazan AN, Boskey ER, Labow B, Ganor O. Insurance policy trends for breast surgery in cisgender women, cisgender men, and transgender men. Plast Reconstr Surg. 2019;144(2):334e-336e.  American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington, VA: American Psychiatric Publishing; 2013. Azul D, Nygren U, Södersten M, Neuschaefer-Rube C. Transmasculine people's voice function: A review of the currently available evidence. J Voice. 2017;31(2):261.e9-261.e23. Boczar D, Huayllani MT, Saleem HY, et al. Surgical techniques of phalloplasty in transgender patients: A systematic review. Ann Transl Med. 2021;9(7):607. Bowman C, Goldberg J. Care of the Patient Undergoing Sex Reassignment Surgery. Vancouver, BC: Vancouver Coastal Health, Transcend Transgender Support & Education Society, and the Canadian Rainbow Health Coalition; January 2006.  Buncamper ME, Honselaar JS, Bouman MB, et al. Aesthetic and functional outcomes of neovaginoplasty using penile skin in male-to-female transsexuals. J Sex Med. 2015;12(7):1626-1634. Byne W, Bradley SJ, Coleman E, et al.; American Psychiatric Association Task Force on Treatment of Gender Identity Disorder. Report of the American Psychiatric Association Task Force on Treatment of Gender Identity Disorder. Arch Sex Behav. 2012;41(4):759-796. Claes KEY, D'Arpa S, Monstrey SJ. Chest surgery for transgender and gender nonconforming individuals. Clin Plast Surg. 2018;45(3):369-380.  Colebunders B, Brondeel S, D'Arpa S, et al. An update on the surgical treatment for transgender patients. Sex Med Rev. 2017;5(1):103-109. Coleman E, Radix AE, Bouman WP, et al. Standards of Care for the Health of Transgender and Gender Diverse People, Version 8.  Int J Transgend. 2022; 23 sup1:S1-S259. Coleman E, Adler R, Bockting W, et al. Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People. Version 7. Minneapolis, MN: World Professional Association for Transgender Health (WPATH); 2011. Coleman E, Bockting W, Botzer M, et al. Standards of Care for the Health of Transsexual, Transgender, and Gender-Nonconforming People, Version 7. Int J Transgend. 2011;13:165-232. Day P. Trans-gender reassignment surgery. NZHTA Tech Brief Series. Christchurch, New Zealand: New Zealand Health Technology Assessment (NZHTA); 2002;1(1).  Djordjevic ML, Bizic MR, Duisin D, et al. Reversal surgery in regretful male-to-female transsexuals after sex reassignment surgery. J Sex Med. 2016;13(6):1000-1007. Eggerstedt M, Hong YS, Wakefield CJ, et al. Setbacks in forehead feminization cranioplasty: A systematic review of complications and patient-reported outcomes. Aesthetic Plast Surg. 2020;44(3):743-749. Falcone M, Preto M, Timpano M, et al. The surgical outcomes of radial artery forearm free-flap phalloplasty in transgender men: Single-centre experience and systematic review of the current literature. Int J Impot Res. 2021;33(7):737-745. Gooren LJG, Tangpricha V. Treatment of transsexualism. UpToDate [serial online]. Waltham, MA: UpToDate; reviewed April 2014. Gorbea E, Gidumal S, Kozato A, et al. Insurance coverage of facial gender affirmation surgery: A review of Medicaid and commercial insurance. Otolaryngol Head Neck Surg. 2021;165(6):791-797. Guan X, Bardawil E, Liu J, Kho R. Transvaginal natural orifice transluminal endoscopic surgery as a rescue for total vaginal hysterectomy. J Minim Invasive Gynecol. 2018;25(7):1135-1136. Hembree et al. Endocrine Treatment of Transsexual Persons:  An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2009; 94(9):3132-3154. Hohman MH, Teixeira J. Transgender surgery of the head and neck. In: StatPearls [Internet]. Treasure Island, FL: StatPearls Publishing; February 27, 2022. Horbach SE, Bouman MB, Smit JM, et al. Outcome of vaginoplasty in male-to-female transgenders: A systematic review of surgical techniques. J Sex Med. 2015;12(6):1499-1512. Hu C-H, Chang C-J, Wang S-W, Chang K-V. A systematic review and meta-analysis of urethral complications and outcomes in transgender men. J Plast Reconstr Aesthet Surg. 2022;75(1):10-24. Jiang D, Witten J, Berli J, Dugi D 3rd. Does depth matter? Factors affecting choice of vulvoplasty over vaginoplasty as gender-affirming genital surgery for transgender women. J Sex Med. 2018;15(6):902-906. Jolly D, Wu CA, Boskey ER, et al. Is clitoral release another term for metoidioplasty? A systematic review and meta-analysis of metoidioplasty surgical technique and outcomes. Sex Med. 2021;9(1):100294. Kaariainen M, Salonen K, Helminen M, Karhunen-Enckell U. Chest-wall contouring surgery in female-to-male transgender patients: A one-center retrospective analysis of applied surgical techniques and results. Scand J Surg. 2016;106 (1):74-79. Lawrence AA, Latty EM, Chivers ML, Bailey JM. Measurement of sexual arousal in postoperative male-to-female transsexuals using vaginal photoplethysmography. Arch Sex Behav. 2005;34(2):135-145. Lawrence AA. Factors associated with satisfaction or regret following male-to-female sex reassignment surgery. Arch Sex Behav. 2003;32(4):299-315. Lee J, Nolan IT, Swanson M, et al. A review of hand feminization and masculinization techniques in gender affirming therapy. Aesthetic Plast Surg. 2021;45(2):589-601. Lee YL, Hsu TF, Jiang LY, et al. Transvaginal natural orifice transluminal endoscopic surgery for female-to-male transgender men. J Minim Invasive Gynecol. 2019;26(1):135-142. Leinung MC, Urizar MF, Patel N, Sood SC. Endocrine treatment of transsexual persons: Extensive personal experience. Endocr Pract. 2013;19(4):644-650. Meriggiola MC, Jannini EA, Lenzi A, et al. Endocrine treatment of transsexual persons: An Endocrine Society Clinical Practice Guideline: Commentary from a European perspective. Eur J Endocrinol. 2010;162(5):831-833. Meyer-Bahlburg HF. Sex steroids and variants of gender identity. Endocrinol Metab Clin North Am. 2013;42(3):435-452. Miller TJ, Wilson SC, Massie JP, et al. Breast augmentation in male-to-female transgender patients: Technical considerations and outcomes. JPRAS Open. 2019;21:63-74.  Morrison SD, Vyas KS, Motakef S, et al. Facial feminization: Systematic review of the literature. Plast Reconstr Surg. 2016;137(6):1759-1770.  Nakatsuka M. [Adolescents with gender identity disorder: Reconsideration of the age limits for endocrine treatment and surgery]. Seishin Shinkeigaku Zasshi. 2012;114(6):647-653. Ngaage LM, Knighton BJ, McGlone KL, et al. Health insurance coverage of gender-affirming top surgery in the United States. Plast Reconstr Surg. 2019;144(4):824-833.  Oles N, Darrach H, Landford W, et al. Gender affirming surgery: A comprehensive, systematic review of all peer-reviewed literature and methods of assessing patient-centered outcomes (Part 1: Breast/chest, face, and voice). Ann Surg. 2022;275(1):e52-e66. Oles N, Darrach H, Landford W, et al. Gender affirming surgery: A comprehensive, systematic review of all peer-reviewed literature and methods of assessing patient-centered outcomes (Part 2: Genital reconstruction). Ann Surg. 2022;275(1):e67-e74. Olson-Kennedy J, Warus J, Okonta V, et al. Chest reconstruction and chest dysphoria in transmasculine minors and young adults: Comparisons of nonsurgical and postsurgical cohorts. JAMA Pediatr. 2018;172(5):431-436. Patel H, Arruarana V, Yao L, et al. Effects of hormones and hormone therapy on breast tissue in transgender patients: A concise review. Endocrine. 2020;68(1):6-15. Raffaini M, Magri AS, Agostini T. Full facial feminization surgery: Patient satisfaction assessment based on 180 procedures involving 33 consecutive patients. Plast Reconstr Surg. 2016;137(2):438-448.. Rafferty J; Committee on Psychosocial Aspects of Child and Family Health; Committee on Adolescence; Section on Lesbian, Gay, Bisexual, and Transgender Health and Wellness. Ensuring comprehensive care and support for transgender and gender-diverse children and adolescents. Pediatrics. 2018;142(4). Salgado CJ, Fein LA. Breast augmentation in transgender women and the lack of adherence amongst plastic surgeons to professional standards of care. J Plast Reconstr Aesthet Surg. 2015;68(10):1471-1472. Sarıkaya S, Ralph DJ. Mystery and realities of phalloplasty: A systematic review. Turk J Urol. 2017;43(3):229-236. Schechter LS. Gender confirmation surgery: An update for the primary care provider. Transgender Health. 2016;1.1:32-40. Seyed-Forootan K, Karimi H, Seyed-Forootan NS. Autologous fibroblast-seeded amnion for reconstruction of neo-vagina in male-to-female reassignment surgery. Aesthetic Plast Surg. 2018;42(2):491-497. Smith YL, Cohen L, Cohen-Kettenis PT. Postoperative psychological functioning of adolescent transsexuals: A Rorschach study. Arch Sex Behav. 2002;31(3):255-261. Spack NP. Management of transgenderism. JAMA. 2013;309(5):478-484. Sutcliffe PA, Dixon S, Akehurst RL, et al. Evaluation of surgical procedures for sex reassignment: A systematic review. J Plast Reconstr Aesthet Surg. 2009;62(3):294-306; discussion 306-308. Tay YT, Lo CH. Use of peritoneum in neovagina construction in gender-affirming surgery: A systematic review. ANZ J Surg. 2022;92(3):373-378. Tonseth KA, Bjark T, Kratz G, et al. Sex reassignment surgery in transsexuals. Tidsskr Nor Laegeforen. 2010;130(4):376-379. Tugnet N, Goddard JC, Vickery RM, et al.  Current management of male-to-female gender identity disorder in the UK. Postgrad Med J. 2007;83(984):638-642. UK National Health Service (NHS), Oxfordshire Primary Care Trust, South Central Priorities Committee. Treatments for gender dysphoria. Policy Statement 18c. Ref TV63. Oxford, UK: NHS; updated September 2009. Van Damme S, Cosyns M, Deman S, et al. The effectiveness of pitch-raising surgery in male-to-female transsexuals: A systematic review. J Voice. 2017;31(2):244.e1-244.e5. Wesp LM, Deutsch MB. Hormonal and surgical treatment options for transgender women and transfeminine spectrum persons. Psychiatr Clin North Am. 2017;40(1):99-111.  Policy History Effective: 05/14/2002 Next Review: 07/11/2024 Review History Definitions Additional Information Clinical Policy Bulletin Notes State Information CA, CO, IL, MD, NY, OR, WA You are now leaving the Aetna website . Links to various non-Aetna sites are provided for your convenience only. Aetna Inc. and its subsidiary companies are not responsible or liable for the content, accuracy, or privacy practices of linked sites, or for products or services described on these sites. Skip to Nav Skip to Main Skip to Footer Saved Articles Newsletters Health Insurers Hit With CA's Largest-Ever Penalty Over Gender-Affirming Care Denials Please try again Two major California health insurers were hit with the state’s largest-ever fines for illegally denying coverage for gender-affirming care in a case that will compel them to revise how they treat patients diagnosed with gender dysphoria. The $850,000 combined penalties against  Blue Cross of California Partnership Plan  and its  Anthem Blue Cross  also require the insurers to hire a dedicated case manager for people with gender dysphoria. Over 150 individuals who were denied coverage for such procedures will see their cases reviewed, and most have already seen reversals, according to the decision. The insurers comply with the decision of the Department of Managed Health Care, a state office that regulates their industry. “We take these matters seriously and have worked directly with the Department of Managed Health Care to identify and implement specific corrective actions to address and resolve the identified matters,” wrote Mike Bowman, a spokesperson for the insurance providers, in a statement to CalMatters. From 2017 to 2020, two California plans by  Anthem Blue Cross and its state partnership  categorized over 20 surgeries, such as facial implants, hair removal, voice therapy and breast augmentation, as “not medically necessary.” But the procedures were covered if they  corrected “abnormal” body structures to create a “normal appearance” for “the target gender.” The language the company employed “could create confusion for the reviewers regarding the medical necessity of the 22 procedures,” wrote Sonia R. Fernandes, deputy director and chief counsel office of enforcement at the Department of Managed Healthcare in an Aug. 15 ruling  against ​​the Blue Cross of California Partnership Plan. In a parallel ruling against Anthem Blue Cross, she wrote that the company “did not provide alternate criteria” to help clinics and hospitals understand when the procedures would qualify for coverage. The plan in question called the procedures “cosmetic” when used to “improve the gender-specific appearance of an individual who has undergone, or is planning to undergo sex reassignment surgery.” The contested plans were in place years after the state implemented the  Insurance Gender Nondiscrimination Act in 2013 , which included many LGBTQ+ Californians into anti-discrimination protections for health coverage. Blue Cross officials acknowledged to regulators that the plans did not comply with state law, but the company and its affiliates have faced growing criticism in the past year over its handling of gender-affirming care. It’s not the first time California’s insurance regulators have cracked down on such forms of discrimination. The department in 2017 issued a $200,000 fine against the insurer Health Net for  gaps in coverage related to gender reassignment surgery  and other procedures. Most recently, in December, the Department of Managed Health Care  announced a $200,000 fine  against  California Physicians’ Service , the doctor reimbursement side of BlueCross, also known as Blue Shield of California. That  decision centered around an individual who was diagnosed with gender dysphoria and received prior-approved services from an out-of-network provider but later saw their health care coverage suspended. The fine has since been paid, and the company has taken corrective action as requested by the state. In this month’s case, regulators said the insurance companies must also provide written confirmation that they have modified their rules, ensured further denials comply with state law and provided training to the doctors and health care administrators. Supported by the California Health Care Foundation (CHCF), which works to ensure that people have access to the care they need, when they need it, at a price they can afford. Visit www.chcf.org to learn more. To learn more about how we use your information, please read our privacy policy. 457 IMAGES Fundraiser by Jordan Bre Davis : Sex reassignment/ breast removal How Gender Reassignment Surgery Works (Infographic) Shocking Discovery in Transgender Breast Surgery Stunning Before And After Photos Depict The Journey Of Gender 2 weeks later after breast surgery... Pin on Trans VIDEO The BEST Doctor For Sexual Reassignment Surgery.. (SRS) Gender Reassignment Surgery (POWER OUTAGE + DETAILS) Transgender Surgeries And My Plans Dr. Chettawut Tulayaphanich, MD TRANS WOMEN ARE MISOGYNISTIC ? Transgender Reddit AITA Couple Reacts Gender Reassignment Surgery Procedure & Pic's COMMENTS Top Surgery (Chest Feminization or Chest Masculinization) Chest Feminization. A breast augmentation procedure may be part of a gender-affirming surgical plan, and can create a more feminine chest appearance. Breast augmentation involves a surgeon inserting a gel or liquid-filled implant into a pocket formed behind the breast tissue or under the pectoral muscle and centering each implant beneath the two nipples. Gender Affirming Surgery: Before and After Photos For zero-depth procedures patients should expect to be in Cleveland for 3-4 days after the surgery and for a full-depth procedure, 7-10 days after surgery. Appointments 216.445.6308. Request an Appointment. See before and after photos of patients who have undergone gender-affirming surgeries at Cleveland Clinic, including breast augmentations ... Transgender Surgical Program For breast or "top" surgery, you are not required to schedule an intake visit with the Transgender Health Program, unless you need a referral for support services. Instead, please contact the Transgender Surgery Program team at 617-726-3525 to learn how to proceed with a surgical consult. Providers should fax referrals to 617-724-7126. Transgender Mastectomy Surgery Transgender Mastectomy (Top Surgery) Elective cosmetic mastectomy, or "top surgery", is a procedure designed to remove unwanted breast tissue in order to create a more masculine chest appearance. Alongside hormone therapy, top surgery is typically one of the first steps for patients who are transitioning from female to male; this may also ... Masculinizing surgery Overview. Masculinizing surgery, also called gender-affirming surgery or gender-confirmation surgery, involves procedures that help better align the body with a person's gender identity. Masculinizing surgery includes several options, such as top surgery to create a more male-contoured chest and bottom surgery that changes the genitals. Gender Affirming Surgical Services This procedure includes removal of breast tissue with masculinizing chest contouring and nipple grafting in some cases. Chest surgery is sometimes performed as an outpatient procedure but some patients may require one night stay in the hospital. ... For more information about the program or to make an appointment, please contact the Transgender ... Gender-Affirming Surgery (Top Surgery) Gender-affirming surgery is a collection of surgical procedures for adults ages 18 and older diagnosed with gender dysphoria. The operations are often referred to as "top surgery" and "bottom surgery.". Duke Health offers several top surgery options to transgender, gender-diverse, nonbinary, and gender-nonconforming adults who want their ... Top Surgery: Cost, Recovery, and Procedure Details The average range for cost of FTM and FTN top surgery is currently between $3,000 and $10,000. The average cost range for MTF and MTN top surgery varies greatly depending on factors such as body ... Your Guide to Nonbinary Options for Top Surgery Breast removal: People assigned female at birth would follow the steps of top surgery that transmasculine people would follow. Depending on your chest size, your own preferences, and your surgeon ... How does female-to-male surgery work? There are multiple forms of gender-affirming surgery, including the removal of breasts — a mastectomy — and the altering of the genital region, known as "bottom" surgery. Examples of ... Feminizing surgery Overview. Feminizing surgery, also called gender-affirming surgery or gender-confirmation surgery, involves procedures that help better align the body with a person's gender identity. Feminizing surgery includes several options, such as top surgery to increase the size of the breasts. That procedure also is called breast augmentation. Guidelines lower minimum age for gender transition treatment and A leading transgender health association has lowered its recommended minimum age for gender transition treatment in teens, including starting sex hormones at age 14 and some surgeries at 15. ... Gabe Poulos, 22, had breast removal surgery at age 16 and has been on sex hormones for seven years. The Asheville, North Carolina, resident struggled ... Does Medicare cover gender reassignment surgery? There is no coinsurance if a person is discharged within 60 days. The standard premium for Medicare Part B in 2024 is $174.70 each month, plus a $240 annual deductible cost. After a person pays ... Gender Confirmation Surgery Request an Appointment. Call 215-662-7300 or request an appointment online. Penn Medicine proudly offers gender confirmation surgery, also known as gender affirmation surgery, to help align your identity. Gender Confirmation (Formerly Reassignment) Surgery: Procedures Double incision. With this procedure, incisions are typically made at the top and bottom of the pectoral muscle and the chest tissue is removed. The skin is pulled down and reconnected at the ... More Trans Teens Are Choosing 'Top Surgery' Small studies suggest that breast removal surgery improves transgender teenagers' well-being, but data is sparse. Some state leaders oppose such procedures for minors. Gender reassignment Female-to-Male Breast Surgery Gender dysphoria occurs in 0.3% of the population. The female-to-male (FTM) gender reassignment surgery in our Alameda and Brentwood practice involves removing both breasts: termed mastectomy, with preservation of the nipple areola complex and with the creation of a contoured, male-looking chest. People undergoing gender reassignment surgery ... Gender Affirmation Surgery: What Happens, Benefits & Recovery Research consistently shows that people who choose gender affirmation surgery experience reduced gender incongruence and improved quality of life. Depending on the procedure, 94% to 100% of people report satisfaction with their surgery results. Gender-affirming surgery provides long-term mental health benefits, too. Gender-Affirming Care for Oregon Health Plan (OHP) Members Mastectomy (breast removal) Gonadectomy (removing testes or ovaries) Hysterectomy (uterus removal) ... For surgery, have completed at least 12 months of hormone therapy (or longer if needed for the surgery). To Get Gender-Affirming Care: Start with your primary care provider (PCP). Your physician and mental health provider can refer you for ... Gender Confirmation Surgery Gender Confirmation (GCS), formerly known as sex reassignment surgery, can be very complex. Find out more about these procedures. Gender Confirmation (GCS), formerly known as sex reassignment surgery, can be very complex. ... Penectomy is the surgical removal of external male genitalia. ... one individual may feel strongly that breast implants ... Gender Transition Surgery Atlanta This Female-to-Male (FTM) or gender reassignment surgery (GRS) allows the patient to live more easily in the male gender role and facilitates a real-life experience. Top Surgery includes bilateral mastectomy (removal of the breasts) and male chest contouring and is one of the most frequent female to male surgeries performed. Gender Affirmation Surgeries Top surgery is surgery that removes or augments breast tissue and reshapes the chest to create a more masculine or feminine appearance for transgender and nonbinary people. Facial gender surgery: While hormone replacement therapy can help achieve gender affirming changes to the face, surgery may help. Facial gender surgery can include a variety ... Gender reassignment surgery: an overview Gender reassignment surgery is a series of complex surgical procedures (genital and nongenital) performed for the treatment of gender dysphoria. ... such as breast enlargement, mastectomy, facial ... Gender Affirming Surgery Medical Necessity. Aetna considers gender affirming surgery medically necessary when criteria for each of the following procedures is met: Requirements for Breast Removal. Signed letter from a qualified mental health professional (see Appendix) assessing the transgender/gender diverse individual's readiness for physical treatment; and. Health Insurers Hit With CA's Largest-Ever Penalty Over Gender ... The department in 2017 issued a $200,000 fine against the insurer Health Net for gaps in coverage related to gender reassignment surgery and other procedures. Most recently, in December, the Department of Managed Health Care announced a $200,000 fine against California Physicians' Service , the doctor reimbursement side of BlueCross, also ... assignment essay homework paper phd report resume review speech thesis